ECG OF THE MONTH

Brian W. Lin, MD; Amal Mattu, MD; William Brady, MD; Jeffrey Tabas, MD
0196-0644/$-see front matter
Copyright © 2018 by the American College of Emergency Physicians.
https://doi.org/10.1016/j.annemergmed.2018.05.002

Figure 1. An accelerated junctional rhythm, with ventricular rate of approximately 65 beats/min. There is 1 mm of ST-segment
depression in lead V2, meeting Sgarbossa’s criteria for the diagnosis of acute myocardial infarction.

Figure 2. The patient’s previous ECG, obtained 9 months earlier, demonstrates a sinus rhythm with occasional premature atrial
complexes and pulse rate of 75 beats/min, with a left bundle branch block pattern. The ST segment in V2 is isoelectric.

[Ann Emerg Med. 2019;73:409-412.]

An 84-year-old man with a history of coronary artery disease drove himself to the emergency department with severe,
aching chest pain radiating to both arms, beginning 3 hours before arrival. He took an aspirin and carvedilol before
arrival, with partial relief. He described intermittent chest pain during the previous 2 weeks. The pains were similar to
those of a previous myocardial infarction he experienced 20 years ago.
His medical history was significant for a quadruple coronary artery bypass graft performed after his first myocardial
infarction, hypertension, and hyperlipidemia. His medications included daily aspirin, carvedilol, and atorvastatin.
A 12-lead ECG was obtained and compared with a previous ECG from 9 months earlier (Figures 1 and 2).
Are there any findings that support the need for emergency catheterization laboratory activation?

For the diagnosis and teaching points, see page 410.

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ECG of the Month Lin et al

Figure 3. Comparison of lead V2 demonstrating an isoelectric ST segment on a previous EKG (A), concordant ST depression on
presentation (B), and resolution of the concordant ST depression after reperfusion therapy (C).

ECG OF THE MONTH

(continued from p. 409)
DIAGNOSIS:
Interpretation
The ECG demonstrated a regular, wide QRS complex rhythm, with ventricular rate at approximately
65 beats/min. Given lack of perceptible P waves and identical QRS morphology on a previous ECG while the
patient was in sinus rhythm, this was most likely an accelerated junctional rhythm.
There was left axis deviation, and the QRS duration was prolonged, at 0.15 msec, with a monomorphic R wave
in lead I and QS in lead V1, consistent with left bundle branch block. Criteria to diagnose left bundle branch block
include a QRS duration of at least 0.12 seconds in the presence of sinus rhythm or a supraventricular rhythm, a
QS or rS complex in lead V1, and an R-wave peak time of at least 0.06 second in leads I, V5, or V6, associated with
the absence of a Q wave in the same lead.1
Compared with the previous ECG, there was new (from previous) discordant ST-segment elevation in leads II, III,
and aVF. However, this ST-segment elevation was not diagnostic of acute coronary occlusion in the setting of
left bundle branch block.
There was also new, concordant ST-segment depression of 1 mm in lead V2, which, according to both the
original and modified Sgarbossa criteria, is diagnostic for acute coronary occlusion in the setting of left bundle branch
block. This dynamic abnormality was noted to normalize in a repeated ECG performed after revascularization

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Lin et al ECG of the Month

(Figure 3). Dynamic change during a short period in a patient with suspected acute coronary syndrome is strongly
suggestive of acute coronary syndrome as well.

CLINICAL COURSE
A failure to initially recognize the “ST-segment elevation myocardial infarction equivalent” findings led to
a 33-minute delay in catheterization laboratory activation after the initial ECG was obtained. When his
troponin level reached 11.73 ng/mL, he was taken urgently to the cardiac catheterization laboratory. His
saphenous vein to the right coronary artery bypass graft was found to be occluded with extensive thrombus
between 2 focal regions of 70% stenosis. The thrombosis was removed and the areas of stenosis were
successfully treated with deployment of 2 drug-eluding stents. The patient had an uneventful hospital admission
and was discharged in stable condition. The ST-segment depression noted in lead V2 was completely resolved
on a follow-up ECG 1 week later.

DISCUSSION
In 1996, Sgarbossa et al1 first described ST-segment criteria for the diagnosis of myocardial infarction in the
setting of left bundle branch block. These criteria were subsequently modified by Smith et al2 and have been
shown to be highly specific (and moderately sensitive) for acute coronary artery occlusion. The Sgarbossa criteria
with the Smith modification are ST-segment elevation greater than or equal to 1 mm and concordant with the
QRS complex in at least one lead; ST-segment depression greater than or equal to 1 mm in any of leads V1 to V3;
and the most negative ratio of ST/S less than –0.25 (in lieu of 5-mm ST-segment elevation) and at least 1 mm
of ST-segment elevation in at least one lead. Presence of any of these findings is strongly suggestive of myocardial
infarction, although their absence does not exclude myocardial infarction.
The admission ECG revealed new ST-segment elevation in leads 2, 3, and aVF that was discordant with the
primarily negative QRS complex deflection in these leads. However, this ST-segment elevation was not diagnostic
of acute coronary occlusion in the setting of left bundle branch block, given that its degree was less than 25% of
the height of the S wave (18% in lead 2, 20% in lead 3, and 19% in lead aVF). In lead V2, there was 1 mm of
ST-segment depression and a primarily negative QRS complex deflection. Concordant ST-segment deviation in
one or more of the V1 to V3 leads is highly predictive of acute myocardial infarction. A 2008 meta-analysis3
reported that this finding has a positive likelihood ratio of 7. Comparison with the previous ECG revealed this
ST-segment deviation to be new.
The 2013 American College of Cardiology Foundation/American Heart Association ST-segment elevation
myocardial infarction guideline revision4 updated the approach to diagnosis of acute myocardial infarction in
patients with left bundle branch block. “New or presumably new [left bundle branch block] at presentation
occurs infrequently, may interfere with ST-elevation analysis, and should not be considered diagnostic of acute
myocardial infarction.in isolation. Criteria for ECG diagnosis of acute [ST-segment elevation myocardial
infarction] in the setting of [left bundle branch block] have been proposed,” with a reference to the original
Sgarbossa criteria.5 More recently, a validation study of the modified Sgarbossa criteria found the modification to
be more sensitive and similar in specificity.6 The recognition of these ECG abnormalities provides an opportunity
to give reperfusion to patients with acute coronary artery occlusion who might not otherwise have received it
because of the presence of left bundle branch block while potentially reducing false cardiac catheterization
laboratory activation. It behooves the emergency physician to recognize the ECG abnormalities of the Sgarbossa
criteria, as well as the modified criteria, which can be somewhat varied and subtle in appearance.

PEARLS
In the setting of left bundle branch block, either 1-mm ST-segment elevation concordant with the QRS complex
in any lead or 1-mm ST-segment depression concordant with a negative QRS complex in any of leads V1 to V3 is
strongly predictive of acute coronary occlusion.

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ECG of the Month Lin et al

In the setting of left bundle branch block, discordant ST-segment elevation in at least one lead with a primarily
negative QRS complex deflection that is 25% or more of the height of the S wave in that lead is strongly predictive
of acute coronary occlusion.
The absence of these 2 ST-segment criteria does not exclude acute coronary occlusion.

Author affiliations: From the Department of Emergency Medicine, Kaiser Permanente San Francisco, San Francisco, CA, University of
Maryland School of Medicine, Baltimore, MD; University of Virginia School of Medicine, Charlottesville, VA; and the Department of
Emergency Medicine, UC San Francisco, San Francisco, CA.
Dr. Tabas is the section editor of ECG of the Month for Annals of Emergency Medicine.

REFERENCES
1. Sgarbossa EB, Pinksi SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left
bundle-branch block. N Engl J Med. 1996;334:481-487.
2. Smith SW, Dodd KW, Henry TD, et al. Diagnosis of ST-elevation 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;60:766-776.
3. 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;52:329-336.
4. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the
American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78-e140.
5. Cai Q, Mehta N, Sgarbossa EB, et al. The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from
falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa criteria ready for prime time? Am Heart J.
2013;166:409-413.
6. Meyers HP, Limkakeng AT, 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;170:1255-1264.

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