Check out the comments from our original post here.
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- Sinus Rhythm
- PR - Normal (~200ms)
- QRS - Prolonged (200ms)
- QT - 400ms
- ST Elevation leads II, III, aVF, V1-5
- ST Depression leads aVR, aVL, V6
- ST changes are discordant i.e. in the opposite direction to the QRS vector
- Discordant change is 'appropriate' in magnitude
- T inversion leads aVR, aVL, V6
- Again discordant to QRS vector
- Deep Swave V1-4
- Notching R wave in V6
- Sgarbossa / Modified Sgarbossa Negative
- Duration of LBBB unknown - nil prior ECG's available
The patient was referred to the cardiology team given his typical history and risk factors.
He underwent early coronary angiogram which revealed multi-vessel diffuse disease (<50% stenosis).
An echo showed:
- Mod to severe dilated left ventricle with severe global impaiment - EF ~21%
- Mild diastolic dysfunction
- Elevated pulmonary artery pressure with normal right ventricular size & function
'New' LBBB remains in the Australian Heart Association guidelines as a trigger for reperfusion therapy. However, the last update of these guidelines was in Sept 2011 and since we have seen a move away from 'new' LBBB or 'presumed new' LBBB being a trigger for urgent reperfusion. The American Heart Association 2013 guidelines removed LBBB as an indication for urgent reperfusion. There is clear variation in international guidelines on this topic and clinicians need to be aware of their own local policies and practices regarding reperfusion criteria.
There are some interesting posts on LBBB significance in ACS here:
- "New" Math: LBBB Does Not Equal STEMI - Medscape
- New Left Bundle Branch Block is a poor indicator of coronary occlusion - Dt Smith's ECG Blog
- R.E.B.E.L. ECG of the Week: LBBB and STEMI - Sgarbossa & Modified Sgarbossa
References / Further Reading
Life in the Fast Lane
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.