Do you remember this patient?

A 34 yom who was admitted with a syncopal attack.

Brugada syndrome

- Persistent STE in V1-V3 - RBBB pattern

THERE IS NO MI

A 81 yof

CC: RLQ abdominal pain for 2-3 days. She also have

nausea, vomiting

No chest pain or S.O.B.Have MI 5 years ago

What is your Dx ?

Does she have AMI?

Answer: NSTEMI!

This is confirm by troponin elevation

“It is important to recognize that BBB is present, because LBBB

prevents any further interpretation of cardiogram, and

RBBB can make interpretation difficult.”

The ECG Made Easy by John R. Hampton

“IMPORTANT: With LBBB, infarct cannot be accurately

diagnosed on EKG.”

Rapid Interpretation of EKG’sby Dale Dubin M.D.

So what is the problem now?

BBB have signs that cover up/mask

the signs of infarction

Let’s revise back the characteristics of

BBB or intraventricular conduction

delay (IVCD).

RABBIT

hiding under

RICE CAKE

showing its

RABBIT EARS

RBBB

hiding under

Right Leads

showing its

‘M’ pattern

MRight Leads

RB

BB

RBBB LBBB

“M” “W” “W” “M”

Right lead Left lead Right lead Left lead

III, aVFV1, V2

I, aVLV5, V6

III, aVF,V1, V2

I, aVL,V5, V6

Splitting of S2

Reversed Splitting of S2

Anymore signs for BBB?

How to name the waves in QRS complex?

What is Q-wave?What is R-wave?What is S-wave?

What is terminal deflection?

Q-R-S

R-S

Q-R

R-S-R’or

“M”

Qor

QS

Let’s improve our vocabulary!

ConcordanceAgreement, concord.

DiscordanceDisagreement, discord.

T–inversion (Discordance with terminal deflection)

ST –displacement from isoelectric line

(Discordance with terminal deflection)

P/S: But this is NO ST-displacement in RBBB

Normal BBB should obey this “normal condition”

So when BBB don’t obey this “normal condition”

there is MI !

SGARBOSSA’s CRITERIA

by Elena B. Sgarbossa

Modified* Sgarbossa’s Criteria

1. Concordant STE > 1 mm

2. Concordant STD > 1 mm in V1, V2, or V3

3. Discordant STE > 5mm *Discordant STE > ¼ QRS

Now let’s put what we learn into practice!

1

2

3

Now let’s make it harder.

Try to determine the presence of MI and also it’s location.

4

5

The patient is an elderly female with a known history of

LBBB who presented to the emergency ward with S.O.B.

6

She did in fact rule in for a myocardial infarction with a

CK of 700 and 21% MB fraction.

To use the rules of concordance in determination of the presence of MI seems easy, but not as easy as we

think.

Final Case

Middle-aged man admitted with recent chest pain.

ECG with the attachment.

7

Hint: There are 7 abnormalities

1. Borderline STC2. LBBB 3. 2° AV block (5:4 & 4:3 patterns) 4. Single PVC5. Acute/evolving infero-lateral MI6. Borderline low QRS voltage 7. Left atrial abnormality.

Cardiac cath. in this patient revealed severe 3 vessel coronary disease with evidence of thrombus in the right posterolateral branch. Left ventriculography showed a reduced left ventricle ejection

fraction of 32% with inf./post. & apical/lat. wall motion

abnormalities.

Additional comments: Mobitz type I (AV Wenckebach)

block is not uncommon with acute inferior MI.

Usually this condition disturbance is transient with inferior MI and does not require temporary or

permanent pacing.

A Word of Caution

NB! This criteria is useful, but final diagnosis of MI should always be confirmed by CE elevation and angiography

(if possible).

Thank you for your attention!

Elevated troponin levels have been documented in other disease states and situations that are not associated with atherosclerotic epicardial coronary artery disease, including the following:

* Pacing, automated implantable cardioverter-defibrillator * Tachyarrhythmias * Hypertension * Myocarditis * Myocardial contusion * Acute and chronic congestive heart failure * Cardiac surgery * Renal failure * Pulmonary embolism * Subarachnoid hemorrhage * Sepsis * Hypothyroidism * Shock