Outcomes in patients with chronicity of left bundle-branch block with possible acute myocardial infarction.

INTRODUCTION: Guidelines derived from patients in clinical trials indicate that emergency department patients with likely myocardial infarction (MI) who have new left bundle-branch block (LBBB) should undergo rapid reperfusion therapy. Whether this pertains to lower risk emergency department patients with LBBB is unclear.

METHODS: A total of 401 consecutive patients with LBBB undergoing an MI rule-out protocol were included. Left bundle-branch blocks were classified as chronic; new; or, if no prior electrocardiogram (ECG) was available, as presumably new. Left bundle-branch blocks were considered concordant if there was ≥1 mm concordant ST elevation or depression. Rates of MI, peak MB values in MI patients, and 30-day mortality were compared across groups.

RESULTS: A majority of patients (64%) had new (37%) or presumably new LBBB (27%). A total of 116 patients (29%) had MI, with no significant difference in prevalence or size of MI among the 3 ECG groups. Myocardial infarction was diagnosed in 86% of patients with concordant ECG changes versus 27% of patients without concordant ECG changes (P < .01). Peak MB was >5× normal in 50% who had concordant ST changes compared to none of those who did not. Concordant ST changes were the most important predictor of MI (odds ratio 17, 95% CI 3.4-81, P < .001) and an independent predictor of mortality (odds ratio 4.3, 95% CI 1.3-15, P < .001); new or presumably new LBBB was neither.

CONCLUSIONS: Most patients with possible MI with new or presumably new LBBB do not have MI. Concordant ECG changes were an important predictor of MI and death. Current guidelines regarding early reperfusion therapy for patients with LBBB should be reconsidered.