期刊
HEART
卷 105, 期 20, 页码 1559-1567出版社
BMJ PUBLISHING GROUP
DOI: 10.1136/heartjnl-2018-314673
关键词
acute coronary syndromes; acute myocardial infarction; ECG; electrocardiogram
资金
- Swiss National Science Foundation
- Swiss Heart Foundation
- European Union
- Cardiovascular Research Foundation Basel
- University Hospital Basel
- Abbott
- Beckman Coulter
- bioMerieux
- BRAHMS
- Roche
- Nanosphere
- Siemens
- Singulex
- 8sense
- Queensland Emergency Medicine Research Foundation
- Christchurch Heart Institute
- Health Research Council
- Heart Foundation of New Zealand
- Christchurch Emergency Care Foundation
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 1hour or 2hours 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 0/2hours allows early and accurate diagnosis of AMI in LBBB.
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