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Original research article
Diagnosis of acute myocardial infarction in the presence of left bundle branch block
  1. Thomas Nestelberger1,
  2. Louise Cullen2,
  3. Bertil Lindahl3,
  4. Tobias Reichlin4,
  5. Jaimi H Greenslade2,
  6. Evangelos Giannitsis5,
  7. Michael Christ6,
  8. Beata Morawiec7,
  9. Oscar Miro8,
  10. Francisco Javier Martín-Sánchez9,
  11. Desiree Nadine Wussler1,
  12. Luca Koechlin1,
  13. Raphael Twerenbold1,
  14. William Parsonage10,
  15. Jasper Boeddinghaus1,
  16. Maria Rubini Gimenez1,
  17. Christian Puelacher1,
  18. Karin Wildi1,
  19. Tobias Buerge1,
  20. Patrick Badertscher1,
  21. Jeanne DuFaydeLavallaz1,
  22. Ivo Strebel1,
  23. Lukas Croton1,
  24. Garnet Bendig11,
  25. Stefan Osswald1,
  26. John William Pickering12,
  27. Martin Than13,
  28. Christian Mueller1
  29. on behalf of the APACE, ADAPT and TRAPID-AMI Investigators
    1. 1 Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
    2. 2 Emergency Department, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
    3. 3 Department of Cardiology, University Hospital Uppsala, Uppsala, Sweden
    4. 4 Department of Cardiology, University Hospital Bern, Bern, Switzerland
    5. 5 Department of Cardiology, Universitaetsklinikum Heidelberg, Heidelberg, Germany
    6. 6 Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
    7. 7 Department of Cardiology, University Hospital, Zabrze, Poland
    8. 8 Department of Emergency Department, Hospital Clinic, Barcelona, Spain
    9. 9 Emergency Department, Hospital San Carlos de Madrid, Madrid, Spain
    10. 10 Department of Cardiology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
    11. 11 Roche Forschungs-, Entwicklungs- und Produktionszentrum, Penzberg, Germany
    12. 12 Department of Medicine, University of Otago, Dunedin, New Zealand
    13. 13 Emergency Department, Christchurch Hospital, Christchurch, New Zealand
    1. Correspondence to Prof. Christian Mueller; Christian.Mueller{at}usb.ch

    Abstract

    Objective Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician.

    Methods We prospectively evaluated the incidence of AMI and diagnostic performance of specific ECG and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. The final diagnosis of AMI was centrally adjudicated by two independent cardiologists according to the universal definition of myocardial infarction.

    Results Among 8830 patients, LBBB was present in 247 (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1%–12%) but high specificity (95%–100%) for AMI. The diagnostic accuracy as quantified by the receiver operating characteristics (ROC) curve of hs-cTnT and hs-cTnI concentrations at presentation (area under the ROC curve (AUC) 0.91, 95% CI 0.85 to 0.96 and AUC 0.89, 95% CI 0.83 to 0.95), as well as that of their 0/1-hour and 0/2-hour changes, was very high. A diagnostic algorithm combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1 hour or 2 hours derived in cohort 1 (45 of 45(100%) patients with AMI correctly identified) showed high efficacy and accuracy when externally validated in cohorts 2 and 3 (28 of 29 patients, 97%).

    Conclusion Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with hs-cTnT/I testing at 0/1 hour or 0/2 hours allows early and accurate diagnosis of AMI in LBBB.

    Trial registration number APACE: NCT00470587; ADAPT: ACTRN12611001069943; TRAPID-AMI: RD001107;Results.

    • acute coronary syndromes
    • acute myocardial infarction
    • ECG/electrocardiogram
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    Footnotes

    • TN and LC contributed equally.

    • Twitter @CRIBasel @Thomas_Nest

    • Contributors TN, JB, RT (cohorts 1 and 3), JG (cohort 2) and CM had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    • Funding Cohort 1 (APACE) was supported by research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, the University Hospital Basel, Abbott, Beckman Coulter, bioMerieux, BRAHMS, Roche, Nanosphere, Siemens, Singulex and 8sense. Cohort 2 (ADAPT) was supported by Queensland Emergency Medicine Research Foundation, Christchurch Heart Institute, Health Research Council and Heart Foundation of New Zealand, and Christchurch Emergency Care Foundation. Cohort 3 (TRAPID-AMI) was sponsored by Roche. The sponsors had no role in the design of the study, analysis of the data, preparation of the manuscript or the decision to submit the manuscript for publication.

    • Competing interests CM has received research grants from the Swiss National Science Foundation and the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, 8sense, Abbott, Alere, AstraZeneca, Beckman Coulter, bioMerieux, BRAHMS, Critical Diagnostics, Nanosphere, Roche, Siemens, Singulex and the University Hospital Basel, as well as speaker or consulting honoraria from Abbott, Alere, AstraZeneca, BG Medicine, bioMerieux, BMS, Boehringer Ingelheim, BRAHMS, Cardiorentis, Daiichi Sankyo, Novartis, Roche, Sanofi, Singulex and Siemens. LC reports grants from Roche and from Abbott, during the conduct of the study, grants from Roche, grants and personal fees from Abbott Diagnostics, grants from Siemens, grants from Radiometer, personal fees from AstraZeneca, and grants from Alere, outside the submitted work. BL has served as a consultant for Roche Diagnostics, Beckman Coulter, Siemens Healthcare Diagnostics, Radiometer Medical, bioMérieux Clinical Diagnostics, Philips Healthcare and Fiomi Diagnostics. TR has received research grants from the Swiss National Science Foundation (PASMP3-136995), the Swiss Heart Foundation, the University of Basel, the Professor Max Cloetta Foundation, and the Department of Internal Medicine, University Hospital Basel, as well as speaker’s honoraria from BRAHMS and Roche. EG has received honoraria for lectures from Roche Diagnostics, BRAHMS, Thermo Fisher and Mitsubishi Chemical Europe. MC has received research support and speaking honoraria from Roche, Thermo Fisher and Novartis. RT reports speaker honoraria from BRAHMS and Roche. WP reports grants from Roche and from Abbott, during the conduct of the study, and grants from Roche, grants and personal fees from Abbott Diagnostics, grants from Siemens, grants from Radiometer, personal fees from AstraZeneca, non-financial support from Bayer, personal fees from Hospira and grants from Alere, outside the submitted work. MRG has received speaking honoraria from Abbott and a research grant from the Swiss Heart Foundation. JB has received speaking honoria from Siemens. GB is an employee of Roche Diagnostics. JWP is supported by a Senior Research Fellowship from the Canterbury Medical Research Foundation, Emergency Care Foundation and Canterbury District Health. All other authors declare that they have no conflict of interest with this study.

    • Ethics approval The studies were carried out according to the principles of the Declaration of Helsinki and approved by the local ethics committee.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data are available from the corresponding author upon request.

    • Collaborators Petra Hillinger, MD (Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland; GREAT network); Karin Grimm, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland; GREAT network); Ursina Honegger, Msc (Department of Cardiology and CRIB, University Hospital Basel, Switzerland); Nicolas Schaerli, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland; GREAT network); Nikola Kozhuharov, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland; GREAT network); Claudia Stelzig, Msc (Department of Cardiology and CRIB, University Hospital Basel, Switzerland); Michael Freese, SN (Department of Cardiology and CRIB, University Hospital Basel, Switzerland); Zaid Sabti, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland; GREAT network); Joan Walter, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland; GREAT network); Lorraine Sazgary, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland; GREAT network); Caroline Kulangara, PhD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland); Kathrin Meissner, RN (Department of Cardiology and CRIB, University Hospital Basel, Switzerland); Deborah Mueller, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland; GREAT network); Beatriz Lopez, MD (GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain); Emilio Salgado, MD (GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain); Esther Rodríguez Adrada, MD (Emergency Department, Hospital Clinico San Carlos, Madrid, Spain); Damian Kawecki MD (2nd Cardiology Department, Zabrze, University of Silesia, Katowice, Poland); Jiri Parenica, MD (University Hospital Brno, Czech Republic); Eva Ganovska, MD (University Hospital Brno, Czech Republic); Katharina Rentsch, PhD (Laboratory Medicine, University Hospital Basel, Switzerland); Andreas Buser, MD (Blood Bank and Department of Hematology, University Hospital Basel, Switzerland); Jens Lohrmann, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland); Roland Bingisser, MD (Emergency Department, University Hospital Basel, Switzerland); Samyut Shrestha, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland); Fabio Stallone, MD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland); Roger Abaecherli, PhD (Department of Cardiology and CRIB, University Hospital Basel, Switzerland; GREAT network); James McCord, MD (Henry Ford Heart & Vascular Institute, Henry Ford Health System, Detroit, Michigan, USA); Richard Nowak, MD (Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK); Richard Body, PhD (Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK; Cardiovascular Sciences Research Group, University of Manchester, Oxford Road, Manchester, UK); Christopher R deFilippi, MD (Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA); Robert H Christenson, PhD (Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA); Mauro Panteghini, MD (Department of Biomedical and Clinical Sciences ’Luigi Sacco', University of Milan Medical School, Milan, Italy); Mario Plebani, MD (Department of Laboratory Medicine, University Hospital Padova, Italy); Franck Verschuren, MD (Cliniques Universitaires St-Luc and Universite Catholique de Louvain, Brussels, Belgium); John French, PhD (Liverpool Hospital and University of New South Wales, Sydney, Australia); Silvia Weiser, PhD (Roche Diagnostics Germany, Penzberg, Germany); Carina Dinkel, PhD (Roche Diagnostics Germany, Penzberg, Germany); Dagmar I Keller, MD (Emergency Department, University Hospital Zürich, Switzerland); Nicolas Geigy, MD (Emergency Department, Kantonsspital Liestal, Switzerland).

    • Correction notice Since this article was published online, changes have been made to figures 1-3 and the supplementary files.

    • Patient consent for publication Obtained.

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