Recognizing ST-Elevation Myocardial Infarction in Bundle Branch Block

Author : Y.S. Pratama *, R. Puspitoadhi *, P. Ardhianto**, Y. Herry**
Upload Date : 19-04-2018

Background: ST-Elevation Myocardial Infraction (STEMI) can generate depolarization and repolarization abnormality. Left Bundle Branch Block (LBBB) and Right Bundle Branch Block (RBBB) is one of phenomenon that can following STEMI and often complicate the diagnosis in the acute setting. Early identification based on electrocardiogram has an important role to decide the diagnosis and management.

Case Presentation:

Case 1

A 67 years old man came to the hospital because chest pain about 7 hours before admission. Pain felt more than 30 minutes, tightness, diaphoresis and didn’t disappeared with rest. He had diabetes mellitus and history of smoking. Physical examination normal and no symptom or sign of heart failure. ECG indicated a complete RBBB with ST segment elevation 1 mm in V2-V5 and troponin 20.71 µL/L. Fibrinolytic with streptokinase was decided. Coronary angiography performed 2 days later and showed hazy in proximal LAD.

Case 2

A 63 years old women complained epigastric pain about 3 hours before admission, followed by nausea and vomiting. She had hypertension, dyspnoea on effort and paroxysmal nocturnal dyspnoea. ECG showed LBBB, vital sign normal with minimal rales and planned to primary PCI. Angiography indicated non-significant stenosis without thrombus formation. Troponin level was 0.04 µL/L. Echocardiography performed 2 days later and indicated global hypokinetic with LVEF 32%.

Discussion: In first case, RBBB with chest pain, we could diagnose STEMI with “appropriate ST-T segment discordance” rule. If ST-T segment not “appropriate discordance” we had to considered to managed patient as STEMI. Usually, although RBBB had repolarization abnormality, ECG still indicated an ST segment elevation slightly above isoelectric in V1-V3. Culprit lesion usually occurred in the proximal LAD before septal branch. Second case we found LBBB with Sgarbossa score 2 point. Based on algorithm from Qiangjun Cai et al, if Sgarbossa < 3 point, we used ST/S ratio in any leads with cut point ≤ -0.25. None of the leads had ST/S ratio ≤ -0.25. Coronary angiography showed no thrombus formation. In this case, LBBB is more often a preexisting marker of underlying structural heart disease such as degenerative conduction disease, chronic ischemic heart disease, cardiomyopathy, or valvular heart disease. Patients with newly developed LBBB from STEMI would most probably be hemodynamically unstable.

Conclusion: Bundle branch block in STEMI is difficult to differentiate, particularly LBBB. Not all LBBB equivalent with STEMI and not all RBBB neglected as STEMI. We can use the “appropriate ST-T segment discordance” rule for RBBB and Sgarbossa and ST/S ratio for LBBB. Early identification based on electrocardiogram has an important role to decide the diagnosis and management in acute setting.


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