The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time?
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Prompt and accurate identification of ST-elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult. The 2004 STEMI guideline recommended emergent reperfusion therapy to patients with suspected ischemia and new or presumably new LBBB. These recommendations have led to frequent false catheterization laboratory activation and inappropriate fibrinolytic therapy because most patients with suspected ischemia and new or presumably new LBBB do not have acute coronary artery occlusion on angiography. The new 2013 STEMI guideline makes a drastic change by removing previous recommendations. Therefore, patients with suspected ischemia and new or presumably new LBBB would no longer be treated as STEMI equivalent. The new guideline fails to recognize that some patients with suspected ischemia and LBBB do have STEMI, and denying reperfusion therapy could be fatal. The Sgarbossa electrocardiography criteria are the most validated tool to aid in the diagnosis of STEMI in the presence of LBBB. A Sgarbossa score of ≥3 has a superb specificity (98%) and positive predictive value for acute myocardial infarction and angiography-confirmed acute coronary occlusion. Thus, we propose a diagnosis and triage algorithm incorporating the Sgarbossa criteria to quickly and accurately identify, among patients presenting with chest pain and new or presumably new LBBB, those with acute coronary artery occlusion. This is a high-risk population in which reperfusion therapy would be denied by the 2013 STEMI guideline. Our algorithm will also significantly reduce false catheterization laboratory activation and inappropriate fibrinolytic therapy, the inevitable consequence of the 2004 STEMI guideline.
Emergency Medical Services
Practice Guidelines as Topic
Published Version (Please cite this version)10.1016/j.ahj.2013.03.032
Publication InfoCaliff, Robert; Wagner, Galen; Barbagelata, Alejandro; Cai, Qiangjun; Mehta, Nilay; Sgarbossa, Elena B; & Pinski, Sergio L (2013). The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time?. American heart journal, 166(3). pp. 409-413. 10.1016/j.ahj.2013.03.032. Retrieved from https://hdl.handle.net/10161/17920.
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Adjunct Professor in the Department of Medicine
Medical degree at the University of Buenos Aires. Residency/Cardiology Fellowship at the Sanatorio Guemes/Favaloro Foundation. Cardiac cath fellow at the Sanatorio Guemes. International Scholar in Artificial Organs at the Cleveland Clinic. Duke Clinical Research Institute research fellow.Faculty member in the Cardiology Division at the University of Texas Medical Branch with the rank of Assoc Professor of Medicine as CCU and Cardiac Cath Lab attending (invasive cardiologist) on all t
Donald F. Fortin, M.D. Professor of Cardiology, in the School of Medicine
Robert Califf, MD MACC, is the Donald F. Fortin, MD, Professor of Cardiology. He is also Professor of Medicine in the Division of Cardiology and remains a practicing cardiologist. Dr. Califf was the Commissioner of Food and Drugs in 2016-2017 and Deputy Commissioner for Medical Products and Tobacco from February 2015 until his appointment as Commissioner in February 2016. Prior to joining the FDA, Dr. Califf was a professor of medicine and vice chancellor for clinical and translational
Associate Professor of Medicine
The general focus of our work is the study of acute ischemic syndromes. I concentrate on determining the value limitations of the clinical ECG. I collaborate with other investigators in various medical centers to measure ECG changes in patients in multiple clinical trials. My ECG core lab activities provide both the data and the research collaboration. The trials are primarily in acute unstable angina and myocardial infarction. Other areas include heart failure, co intervention
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