The Journal of Emergency Medicine, Vol. 51, No. 1, pp. 1–8, 2016
! 2016 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2016.02.029
Original
Contributions
COMPARISON OF THE QRS COMPLEX, ST-SEGMENT, AND T-WAVE AMONG
PATIENTS WITH LEFT BUNDLE BRANCH BLOCK WITH AND WITHOUT ACUTE
MYOCARDIAL INFARCTION
Kenneth W. Dodd, MD,*† Kendra D. Elm, BS,*‡ and Stephen W. Smith, MD*‡
*Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, †Department of Internal Medicine,
Hennepin County Medical Center, Minneapolis, Minnesota, and ‡Department of Emergency Medicine, University of Minnesota Medical
School, Minneapolis, Minnesota
Reprint Address: Kenneth W. Dodd, MD, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue,
Minneapolis, MN 55415
, Abstract—Background: The modified Sgarbossa
criteria have been validated as a rule for diagnosis of acute
coronary occlusion (ACO) in left bundle branch block
(LBBB). However, no analysis has been done on differences
in the QRS complex, T-wave, or ST-segment concordance of
< 1 mm in the derivation or validation studies. Furthermore,
there was no comparison of patients with acute myocardial
infarction (AMI) but without ACO (i.e., non–ST-elevation
myocardial infarction [non-STEMI]) to patients with ACO
or without AMI (no MI). Objective: We compare findings
involving the QRS amplitude, ST-segment morphology,
ST-concordance < 1 mm, and T-waves in patients with
LBBB with ACO, non-STEMI, and no MI. Methods: Retrospectively, emergency department patients were identified
with LBBB and ischemic symptoms but no MI, with angiographically proven ACO, and with non-STEMI. Results:
ACO, non-STEMI, and no MI groups consisted of 33, 24,
and 105 patients. The sum of the maximum deflection of
the QRS amplitude across all leads (SQRS) was smaller in
patients with ACO than those without ACO (101.5 mm vs.
132.5 mm; p < 0.0001) and a cutoff of SQRS < 90 mm was
92% specific. For ACO, non-concave ST-segment
morphology was 91% specific, any ST concordance $
1 mm was 95% specific, and any ST concordance $
0.5 mm was 94% sensitive. For non-STEMI, terminal
T-wave concordance, analogous to biphasic T-waves, was
moderately sensitive at 79%. Conclusions: We found differences in QRS amplitude, ST-segment morphology, and
T-waves between patients with LBBB and ACO, nonSTEMI, and no MI. However, none of these criteria outperformed the modified Sgarbossa criteria for diagnosis of ACO
in LBBB. ! 2016 Elsevier Inc. All rights reserved.
, Keywords—left bundle branch block; acute myocardial
infarction; QRS complex; ST-segment; T-wave
INTRODUCTION
The electrocardiogram (ECG) remains the fastest tool for
early diagnosis of acute myocardial infarction (AMI).
Historically, the belief that left bundle branch block
(LBBB) hopelessly obscures the diagnosis of AMI by
ECG has impeded work on this topic. The confusion
has come because, at baseline, patients with LBBB
exhibit discordance of the QRS complex, ST-segment,
and T-wave. That is, patients with LBBB have
ST-elevation in leads with negative QRS complexes
(Figure 1) and ST-depression, as well as negative Twaves, in leads with positive QRS complexes. When
this ‘‘rule of appropriate discordance’’ in LBBB is kept
in mind, the diagnosis of acute coronary occlusion
(ACO), which is the anatomic substrate for ST-elevation
Kenneth W. Dodd and Kendra D. Elm contributed equally to
this work.
RECEIVED: 15 November 2015; FINAL SUBMISSION RECEIVED: 25 January 2016;
ACCEPTED: 3 February 2016
1
2
K. W. Dodd et al.
loss of specificity. Third, we hypothesized that nonconcave ST-segment morphology would not be a sensitive or specific marker of ACO, in contrast to previously
published guidelines (3). Fourth, we hypothesized that
patients with ACO would exhibit hyperacute T-wave
equivalents more frequently than non-ACO patients, as
manifested by an increased T-wave amplitude (TWA)
and discordant TWA/QRS-amplitude ratio (T/QRS).
Finally, we hypothesized that patients with non-STEMI
and LBBB would more frequently have concordant
T-waves, a presumed analogue to T-wave inversions in
ECGs with normal conduction.
METHODS
Study Design and Population
Figure 1. Diagram of measurements and morphologies. The
main diagram demonstrates normal discordance in left bundle
branch block with a negative maximum QRS amplitude (i.e., an
S-wave) and resulting positive T-wave, as well as concave STsegment elevation. Appropriate measurements are also
demonstrated: S-wave = 19 mm; ST = 1.5 mm; T-wave amplitude (TWA) = 9 mm; ST/S ratio = 1.5/19 = 0.08; discordant T/
QRS ratio (i.e., T/S ratio in this example) = 9/19 = 0.47. Morphologies of straight (A) and convex (B) ST-segments, as well as
majority T-wave concordance (C) and terminal T-wave concordance (D) are also shown.
myocardial infarction (STEMI), may be made with far
more accuracy than previously believed. The modified
Sgarbossa criteria were 91% sensitive and 90% specific
for diagnosis of ACO in LBBB in the derivation trial
(Table 1), and have recently been validated with 80%
sensitivity and 99% specificity (1,2). No specific
analysis of the QRS complex, ST-segment morphology,
concordant ST-deviation of 10 ng/mL (implying probable ACO at the
time of ECG).
The non-STEMI group consisted of patients who were
adjudicated as AMI by a study author (S.W.S) with 24-h
troponin-I > 99% upper reference limit (99% upper reference limit range was 0.1–0.6 ng/mL for assays used
during the study period) in which ACO was excluded
by either angiogram showing no culprit lesion, a lesion
but no angiographic occlusion and peak troponin
10 ng/
mL. There were 105 no-MI patients that had negative serial troponin-I for up to 24 h. An additional 24 patients
met adjudication criteria for non-STEMI. In total, 162 patients were included in the study. As reported in the original study, there was good inter-rater reliability of the
measurements (1). Patient characteristics for each group
are shown in Table 2.
QRS Amplitude in LBBB and ACO
For the sum of QRS amplitudes across all 12 leads
(SQRS), the median value was 101.5 mm (IQR 82.5–
115.5 mm) for ACO, 129.75 mm (IQR 103.4–142.3 mm)
for non-STEMI, and 132.5 mm (IQR 109.5–159.0 mm)
Table 2. Patient Characteristics
Characteristic
ACO
(n = 33)
Non-STEMI
(n = 24)
No MI
(n = 105)
Age, y (95% CI)
Mean no. (%)
Peak troponin-I, ng/mL (95% CI)
72.8 (68.4–77.2)
20 (61)
114.7 (65.3–164.1)
70.9 (66.2–75.7)
8 (33)
3.5† (2.34–4.66)
65.5* (61.8–69.2)
50 (48)
ACO = acute coronary occlusion; CI = confidence interval; n/a = not applicable; no MI = without acute myocardial infarction; nonSTEMI = non–ST-elevation myocardial infarction.
* p < 0.05 compared to ACO.
† p < 0.001 compared to ACO.
4
K. W. Dodd et al.
Table 3. Criteria for Diagnosis of Acute Coronary Occlusion vs. Non–Acute Coronary Occlusion in Left Bundle Branch Block
Criteria
QRS amplitude
SQRS < 90 mm
ST-segment concordance
Concordant ST-elevation $ 0.5 mm in any lead
Concordant ST-depression $ 0.5 mm in leads V1–V3
Concordant ST-depression $ 0 mm in leads V1–V3
Concordant ST-depression $ 0.5 mm in any lead
Concordant ST-depression $ 1.0 mm in any lead
Any concordance $ 0.5 mm
Any concordance $ 1.0 mm
ST-segment morphology
Non-concave (convex or straight) ST-segment
T-wave to QRS amplitude ratio
Discordant T/QRS > 1.25
T-wave concordance
Majority T-wave concordance in any lead
T-wave concordance in leads V5 or V6
for no MI (p < 0.0001 for both non-STEMI and no MI
compared with ACO). When non-ACO patients were
compared with ACO patients, the median SQRS was
also significantly higher for the non-ACO group
(132.5 mm [IQR 108.5–156.5 mm]; p < 0.0001). Using
a cutoff value of SQRS 90% specificity for diagnosis of ACO (Table 3).
ST-Segment Concordance in LBBB and ACO
ST-segment concordance comparisons in LBBB with
ACO are found in Table 3. When a cutoff of $0.5 mm
of concordant ST-elevation was used in any lead or
$0.5 mm of concordant ST-depression in V1–V3, there
was no significant difference in sensitivity or specificity
when compared with the previously reported cutoffs of
$1 mm (p = NS, Tables 1 and 3). A composite rule
with combination of any concordance $0.5 mm or ST/
S ratio of # !0.25 yielded 100% (95% CI 87–100) sensitivity and 57% (95% CI 47–65) specificity for the diagnosis of ACO in LBBB.
Sensitivity, % (95% CI)
Specificity, % (95% CI)
33 (19–52)
92 (85–96)
64 (45–79)
24 (12–43)
39 (23–56)
70 (67–82)
61 (42–77)
94 (78–99)
73 (54–86)
92 (86–96)
99 (95–100)
85 (78–91)
75 (51–84)
95 (95–100)
70 (61–77)
95 (88–97)
55 (37–71)
91 (84–96)
45 (28–63)
93 (87–97)
76 (57–88)
49 (31–66)
62 (53–70)
79 (69–84)
p < 0.05). Using a cutoff of discordant T/QRS $1.25
yielded >90% specificity for ACO (Table 3). But this statistical difference in discordant T/QRS is entirely due to
the difference in QRS amplitudes.
T-Wave Concordance in LBBB
In non-STEMI compared with no MI, terminal T-wave
concordance of >0.5 mm in any lead was the most sensitive of all criteria analyzed (Table 4). This criterion, as
well as majority T-wave concordance in any lead and majority T-wave concordance in leads V5 or V6, was more
sensitive for diagnosis of non-STEMI than the modified
Sgarbossa criteria (p < 0.05 for all).
As expected, majority T-wave concordance in any lead
was less specific for ACO than the modified Sgarbossa
criteria (p < 0.05, Table 3). T-wave concordance in V5
or V6 was less sensitive and less specific for ACO than
the modified Sgarbossa criteria (p = NS).
For diagnosis of any MI (i.e., ACO and non-STEMI)
compared to no MI, the addition of terminal T-wave
concordance to the modified Sgarbossa criteria resulted
ST-Segment Morphology in LBBB and ACO
Non-concave ST-segment morphology in at least one lead
with ST-elevation $1 mm was present in 18 (55%) patients with ACO compared with 11 (9%) non-ACO patients (p < 0.05) resulting in >90% specificity (Table 3).
Table 4. Criteria for Diagnosis of Non–ST-Elevation
Myocardial Infarction vs. No Acute Myocardial
Infarction in Left Bundle Branch Block
T-Wave Amplitude and T-Wave Ratios in LBBB and ACO
Modified Sgarbossa criteria
Terminal T-wave
concordance in any lead
Majority T-wave
concordance in any lead
Majority T-wave
concordance in leads V5 or V6
The maximum TWA was similar for the ACO (9 mm
[IQR 6.5–11 mm]) and non-ACO groups (8 mm [IQR
6.5–11 mm]; p = NS). The median discordant T/QRS ratio was significantly larger for ACO (1.08 [IQR 0.8–1.5])
compared with non-ACO (0.70 [IQR 0.43–0.75];
Criteria
Sensitivity, % Specificity, %
(95% CI)
(95% CI)
8 (2–29)
79* (57–92)
88 (79–93)
47* (37–57)
46* (26–67)
64* (54–73)
29* (13–51)
79* (70–86)
* p < 0.05 compared to the modified Sgarbossa criteria.
Diagnosis of Acute Myocardial Infarction in Left Bundle Branch Block
Table 5. Rules for Diagnosis of Any Acute Myocardial
Infarction vs. No Acute Myocardial Infarction in
Left Bundle Branch Block
Rules
Modified Sgarbossa criteria
Modified Sgarbossa criteria
or majority T-wave concordance
in any lead
Modified Sgarbossa criteria or
terminal T-wave concordance
in any lead
Sensitivity,
% (95% CI)
Specificity,
% (95% CI)
54 (41–68)
79* (66–88)
88 (79–93)
56* (46–66)
91* (80–97)
43* (33–53)
5
reported that $1 mm concordant ST-elevation in at least
one lead and $1 mm concordant ST-depression in leads
V1–V3 has high specificity for ACO with relatively low
sensitivity. In this study, we found that lowering the cutoff
to $ 0.5 mm of concordant ST-elevation or ST-depression
increased the sensitivity of these criteria, while retaining
a relatively high specificity with each criterion analyzed
independently. When a composite rule consisting of any
concordance (ST-elevation or ST-depression) $ 0.5 mm
or an ST/S ratio # !0.25 was analyzed, the sensitivity
was 100% but the specificity did decrease significantly.
* p < 0.05 compared to the modified Sgarbossa criteria.
ST-Segment Morphology in LBBB and ACO
in >90% sensitivity (p < 0.05), but at the expense of specificity. Addition of majority T-wave concordance also
significantly increases sensitivity, but to a lesser extent
(Table 5).
DISCUSSION
Salient Findings
We analyze several QRS, ST-segment, and T-wave characteristics in patients with LBBB and angiographically
defined ACO, LBBB, and non-STEMI, and LBBB
without AMI. We found that the SQRS voltage was
significantly lower in patients with ACO compared to
non-ACO controls. With regard to ST-segment changes,
we found that any ST concordance $1 mm was 95% specific for ACO, while a cutoff of $0.5 mm was 94% sensitive for ACO. We also found that non-concave STsegment morphology was 91% specific for ACO, but
had poor sensitivity. For non-STEMI, terminal T-wave
concordance had relatively high sensitivity compared to
the other criteria studied, but this was not sufficient to
add utility to the diagnosis.
QRS Amplitude in LBBB and ACO
Comparatively low amplitude of the QRS complex has
been found to correlate with areas of ST-segment elevation and eventual myocardial loss in patients with normal
cardiac conduction (7,8). In a study of 143 patients with
normal conduction and ‘‘subtle’’ anterior ACO
compared to 171 patients with early repolarization,
R-wave amplitude in V2–V4 was lower in patients with
subtle anterior ACO than those with early repolarization
(9). In LBBB, we found that patients with ACO had lower
QRS voltage on the ECG compared to non-ACO patients.
ST-Segment Concordance in LBBB and ACO
ST-segment concordance $1 mm has been well-studied
in LBBB and AMI (1,2,10). We have previously
Wang et al. asserted that upward convexity is the key to
diagnosing ACO in LBBB (3). Analysis of ST-segment
morphology in 171 patients with normal conduction (56
with AMI) presenting with ST-elevation and symptoms
of acute coronary syndrome done by Brady et al. reported
that upwardly non-concave ST-segment morphology had
97% sensitivity and 77% specificity for AMI in any coronary territory (6). Importantly, Brady et al. used creatine
kinase-MB (CK-MB) for diagnosis of AMI and thus
included both STEMI and non-STEMI patients. Kosuge
et al. studied 77 consecutive patients with proven left
anterior descending coronary artery (LAD) occlusion
and found that 53 (69%) had non-concave morphology
(41 with straight and 12 with convex) and 24 (31%) had
concave morphology (11). Our study found similar results for utility of non-concave morphology to diagnose
ACO in LBBB, with sensitivity of 55% and specificity
of 91%. However, in the diagnosis of ACO in LBBB,
the modified Sgarbossa criteria were far more sensitive
than morphology analysis without loss of specificity.
T-Waves in LBBB and ACO
In the largest study on hyperacute T-waves in normal conduction, Collins et al. screened 13,393 adult ECGs for
abnormally large TWA and then excluded patients with
other causes of large TWA (e.g., BBB, hyperkalemia,
acute hypertension, acute central nervous system events,
valvular heart disease, and ventricular hypertrophy) (12).
Interestingly, LBBB was the most common reason patients were classified as having a primary cause of high
TWA. Patients with ‘‘clinically verifiable’’ AMI, as determined by the treating physician, were classified as having
hyperacute T-waves, while other patients were called
early repolarization variants. The study identified a combination of four criteria that characterize hyperacute
T-waves with 90% specificity and 62% sensitivity: T/
QRS >0.75, ST/T >0.25, STE >3 mm, and age older
than 45 years. In another study, Smith et al. compared
ECGs with normal conduction and proven LAD
6
occlusion to those with early repolarization and found no
significant difference in TWA in leads V2–V4, although
the T/QRS ratio was higher in LAD occlusion (9). Indeed,
in this study, we found that patients with ACO had no difference in TWA, but they did have a higher median
discordant T/QRS ratio than both non-STEMI and no
MI groups; a discordant T/QRS >1.25 yielded >90%
specificity for ACO. Thus, the T/QRS differences are
the result of decreases in the QRS amplitude in patients
with LBBB and ACO.
T-Waves in LBBB and Non-STEMI
Jacobsen et al. performed a retrospective analysis of Twave findings in 468 patients with non-STEMI or unstable angina with normal conduction (13,14). They
reported biphasic T-waves, T-waves with abnormal axis
(e.g., inverted T-waves), and T-waves with amplitude
outside the normal range were associated with adverse
outcomes at 30 days and 1 year (13,14). In Jacobsen
et al.’s 2001 study, 62% of patients with ST-depression
and 35% of patients without ST-depression were found
to have biphasic T-waves. A study by Hyde et al. found
16% of 353 patients with normal conduction and acute
coronary syndrome (including STEMI, non-STEMI,
and unstable angina) had T-wave inversion (15). In this
study of LBBB patients, we found a higher rate of terminal T-wave concordance (sensitivity 79%) than majority
T-wave concordance (sensitivity 46%) among nonSTEMI patients; these measures may be analogous to
biphasic T-waves and T-wave inversions, respectively.
Diagnosis of Any MI in LBBB
As expected, both the modified Sgarbossa criteria and the
original Sgarbossa criteria (data not shown) have poor
sensitivity for any MI. This is because the modified Sgarbossa criteria were derived from a population of patients
with ACO and non-STEMI patients were included in the
control group. The original Sgarbossa criteria were
derived among patients with any MI diagnosed by CKMB, yet these still had poor sensitivity for any MI in
the original study and had only 20% sensitivity in a systematic review (16). However, in Sgarbossa’s original
study, positive T-waves in leads V5 and V6 (i.e., concordant T-waves in V5 and V6) had 92% specificity for any
MI. When terminal T-wave concordance, our most sensitive criterion for non-STEMI, was added to the modified
Sgarbossa criteria for the diagnosis of any MI, the sensitivity increased significantly (91%); however, this was at
the expense of a much lower specificity (43%).
Overall, none of the criteria we studied for the diagnosis of any MI in LBBB are useful clinically because
the prevalence of AMI (both STEMI and non-STEMI)
K. W. Dodd et al.
in unselected LBBB patients presenting to the ED is
only around 7% (17). With such a low prevalence, high
specificity is vital to avoid a very low positive predictive
value.
Limitations
Limitations of our study include a retrospective design
with relatively small sample size of arterial occlusions,
which decreases the ability to detect meaningful differences among subgroups. Our sample size is limited primarily by the fact that AMI is rare in patients
presenting to the emergency department with LBBB
and symptoms suggestive of myocardial ischemia (17).
However, with the exception of the validation of the
modified Sgarbossa criteria (n = 45 ACO), this study is
the largest of its kind on an unselected cohort of proven
coronary occlusion in the presence of LBBB. Overall, a
larger multivariate analysis of these criteria, and combinations thereof, is needed. This will require data from
either a larger multicenter retrospective trial or, ideally,
a very large prospective trial with baseline clinical characteristics of patients as well as angiographic, echocardiographic, and other clinical outcomes data. If
clinically useful criteria are identified, they should need
to be incorporated into automated ECG algorithms so
that clinicians do not have to remember and make complex measurements.
CONCLUSIONS
Our study found that patients with LBBB and AMI do
have QRS amplitude, ST-segment morphology, and Twave differences that are analogous to patients with
normal conduction. While several criteria were quite specific or sensitive for the diagnosis of ACO in LBBB,
none, either alone or in combination, outperformed the
modified Sgarbossa criteria, which remain superior to
other ECG criteria in the diagnosis of ACO in LBBB.
REFERENCES
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myocardial infarction in the presence of left bundle branch block
with the ST-elevation to S-wave ratio in a modified Sgarbossa
rule. Ann Emerg Med 2012;60:766–76.
2. Meyers HP, Limkakeng AT Jr, Jaffa EJ, et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of
left bundle branch block: a retrospective case-control study. Am
Heart J 2015;170:1255–64.
3. Wang K, Asinger RW, Marriott HJL. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003;
349:2128–35.
4. Surawicz B, Childers R, Deal BJ, Gettes LS. AHA/ACCF/HRS recommendations for the Standardization and interpretation of the
electrocardiogram. Part III: intraventricular conduction disturbances. J Am Coll Cardiol 2009;53:976–81.
Diagnosis of Acute Myocardial Infarction in Left Bundle Branch Block
5. Smith SW. Upwardly concave ST segment morphology is common
in acute left anterior descending coronary occlusion. J Emerg Med
2006;31:69–77.
6. Brady WJ, Syverud SA, Beagle C, et al. Electrocardiographic STsegment elevation: the diagnosis of acute myocardial infarction
by morphologic analysis of the ST segment. Acad Emerg Med
2001;8:961–7.
7. Salerno DM, Asinger RW, Elsperger J, et al. Increasing precordial
QRS voltage correlates with improvement in left ventricular function following anterior myocardial infarction. J Electrocardiol
1988;21:303–12.
8. Kilpatrick D, Bell AJ. The relationship of ST elevation to eventual
QRS loss in acute inferior myocardial infarction. J Electrocardiol
1989;22:343–8.
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2012;60:45–56.
10. Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in
the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for
Occluded Coronary Arteries) Investigators. N Engl J Med
1996;334:481–7.
7
11. Kosuge M, Kimura K, Ishikawa T, et al. Value of ST-segment elevation pattern in predicting infarct size and left ventricular function at
discharge in patients with reperfused acute anterior myocardial
infarction. Am Heart J 1999;137:522–7.
12. Collins MS, Carter JE, Dougherty JM, et al. Hyperacute T-wave
criteria using computer ECG analysis. Ann Emerg Med 1990;19:
114–20.
13. Jacobsen MD, Wagner GS, Holmvang L, et al. Clinical significance
of abnormal T-waves in patients with non-ST-Segment elevation
acute coronary syndromes. Am J Cardiol 2001;88:1225–9.
14. Jacobsen MD, Wagner GS, Holmvang L, et al. Quantitative T-wave
analysis predicts 1 year prognosis and benefit from early invasive
treatment in the frisc ii study population. Eur Heart J 2005;26:
112–8.
15. Hyde TA, French JK, Wong C, et al. Four-year survival of patients
with ST-segment elevation and prognostic significance of 0.5-mm
ST-segment depression. Am J Cardiol 1999;84:379–85.
16. Tabas JA, Rodriguez RM, Seligman HK, et al. Electrocardiographic
criteria for detecting acute myocardial infarction in patients with
left bundle branch block: a meta-analysis. Ann Emerg Med 2008;
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