The first complex above is up, the second is down and the third is. The criteria sgarbossa 1 that can be used in case of a lbbb and suspicion of infarction are. Sgarbossas criteria are a set of electrocardiographic findings generally used to identify myocardial infarction also called acute myocardial infarction or a heart attack in the presence of a left bundle branch block lbbb or a ventricular paced rhythm myocardial infarction mi is often difficult to detect when lbbb is present on ecg. The criteria of stsegment depression in v1, v2 or v3 had similar test characteristics to sgarbossas study sensitivity of 19%, specificity of 81% compared with a sensitivity of 29% and specificity of 82% in sgarbossas study. The picture above is the best illustration i could find. Smith himself also wrote of a nice case for ep monthly about his modified criteria. The sgarbossa criteria help with that determination. The sgarbossa criteria consist of stsegment elevation of 1 mm or more concordant with the qrs complex i. Sgarbossa s is a well accepted approach at determining which lbbb are having an mi. Sgarbossa criteria it has been traditionally thought taught that mi cannot be diagnosed if lbbb is present due to characteristic ecg changes caused by altered ventricular depolarization.
The sgarbossa criteria is described in the cardiology literature by neeland et al who conclude in their paper. Patients with a suspected acs in the setting of lbbb represent a much more heterogeneous population than stemi without bbb and present unique diagnostic and therapeutic challenges to the clinician. Criteria for the ecg diagnosis of stemi in the setting of lbbb have been developed and may help identify patients presenting with chest pain and lbbb who are more likely to be experiencing an mi. If you recall there are two main problems with using 5 mm as an arbitrary cutoff for discordant stelevation in the presence of left bundle branch block. Sgarbossas criteria for mi in left bundle branch block. Sgarbossa criteria in bundle branch blocks and paced. Diagnosis of acute myocardial infarction in the presence. The prevalence of the lbbb criteria defined by strauss et al. Sgarbossas is a well accepted approach at determining which lbbb are having an mi. Validation of the modified sgarbossa criteria filed under.
Sgarbossa e, pinski s, et al for the gusto1 investigators. Making sense of sgarbossas criteria ecg medical training. Sgarbossa identified 3 criteria used in a 10point scale that improved the specificity of the diagnosis of stemi in patients with lbbb. In 1996 sgarbossa et al 3 identified three ekg criteria that may improve the diagnosis of stemi in patients with left bundle branch block 1.
Sgarbossa criteria background in patients with left bundle branch block lbbb or ventricular paced rhythm, infarct diagnosis based on the ecg is difficult. The reason for not meeting strauss criteria was mainly due to short qrs duration mds profile on linkedin, the worlds largest professional community. In this final part of the series id like to talk about smiths modification to sgarbossa s criteria and the importance of serial ecgs. Left bundle branch block lbbb diagnosis and management. Its prevalence, mechanism, detailed electrocardiographic ecg features, and effective treatments are not well described. Methods we prospectively evaluated the incidence of ami and diagnostic performance of specific ecg and highsensitivity cardiac troponin hsctn criteria in patients. A 76yearold woman presents to the ed with chest pain that radiates to the neck, jaw and teeth. Sgarbossa criteria for diagnosis of myocardial infarction mi in left bundle branch block lbbb total number of pages found. The electrocardiographic criteria for the diagnosis of infarction were then tested in an independent sample of patients presenting with acute chest pain and left bundlebranch block. Found on the lifenet receiving station lbbb with concordant stdepression in leads v3 and v4. Discordant stsegment elevation in lbbb or paced rhythm. What are the sgarbossa criteria for myocardial infarction in lbbb.
Sgarbossa criteria was also used in the analysis, although the authors primarily examined the presence of concordant st changes defined as the presence of one of the following criteria. St elevation 1mm in leads with a positive qrs complex concordance in st deviation score 5. The most commonly used criteria to help differentiate an acute mi is the sgarbossa criteria from the gusto1 trial. The baseline st segments and t waves tend to be shifted in a discordant direction appropriate discordance, which can mask or mimic acute myocardial infarction.
The group consisted of 256 patient files fulfilling the following criteria. Criteria for left bundle branch block lbbb qrs 0,12 sec broad monomorphic r waves in i and v6 with no q waves broad monomorphic s waves in v1, may have a small r wave. Consequently, a lbbb makes it difficult to diagnose an acute mi. Best of the best in cardiology university of maryland. Electrocardiographic diagnosis of myocardial infarction in. The first thing you have to do is determine the direction of the major qrs deflection. Either concordance or excessive discordance of the st segment is associated with an mi, this has a high specificity but lower sensitivity. Sgarbossa criteria help look for stemis in people with lbbb left bundle branch block ecg criteria. Identifying ami in the presence of lbbb sgarbossas criteria part i. Sgarbossas criteria for diagnosing ami in the presence of. In normal lbbb the st segment and t wave should be discordant to the majority of the qrs. 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. Left bundle branch block presents a dilemma for many clinicians in the evaluation of chest pain or other signs and symptoms of acs and its easy to see why.
Sgarbossa criteria can help interpret the ecg for stemi in the setting of lbbb. Painful left bundle branch block lbbb is a rarely diagnosed chest pain syndrome caused by intermittent lbbb in the absence of myocardial ischemia. Diagnosis of stelevation myocardial infarction in the. Criteria to diagnose acute mi in patients with prior lbbb. Making sense of sgarbossas criteria chest pain and left.
In a lbbb, the left ventricle is depolarized later than the right ventricle. In the original sgarbossa criteria, a score of pdf available in canadian medical association journal 18815 april 2016 with 612 reads how we measure reads. A new lbbb is always pathological and can be a sign of myocardial infarction. Intracranial hemorrhage deep t wave inversions jama internal medicine july 2015 volume 175, number 7. Qiangjun cai, md,a,b,e nilay mehta, do,a,e elena b. As discussed in this article by stephen smith, modified sgarbossa criteria have been created to improve diagnostic accuracy. Positive or negative concordance in precordial leads with no rs seen. Lbbb should be considered a stemi equivalent only if patient is hemodynamically unstable or has acute heart failure, or patient has concordant st segment changes sgarbossa rules a or b new lbbb and ami. Published in 1996, three sgarbossa criteria were described. See the complete profile on linkedin and discover elenas. Identifying ami in the presence of lbbb sgarbossas criteria part ii. Common ecg pitfalls in diagnosing mi false positives. The most important change is the modification of the rule for excessive discordance the use of a 5 mm cutoff for excessive discordance was arbitrary and nonspecific for example, patients with lbbb and large voltages will commonly have.
With most lbbbs there is what is called appropriate disconcordance. Josephsons sign notching near the nadir of the s wave. The pain is associated with nausea, dyspnea, and diaphoresis. The sgarbossa criteria is used in the diagnosis of an acute myocardial infarction when a left bundle branch block is present. Making sense of sgarbossas criteria chest pain and left bundle branch block part 1. Cardiology, lbbb, sgarbossa criteria, stemi september 29th, 2016 leave a comment it has been recognized since the 1940s that the presence of a left bundle branch block lbbb obscures the ekg diagnosis of myocardial infarction mi. Prevalence of manual strauss lbbb criteria in patients. Subsequent modifications make it even more accurate. Some valuable criteria help diagnose true stemi in patients with lbbb and symptoms suggestive of ami. Making sense of sgarbossa s criteria chest pain and left bundle branch block part 3. Its often difficult to identify an mi for patients with existing left bundle branch blocks lbbb. A modified sgarbossa criteria was developed to increase the sensitivity.