thrombolysis in a patient with chest pain and LBBB on ECG
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thrombolysis in a patient with chest pain and LBBB on ECG
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A 50 years man comes to ER with acute chest pain of 6 hours duration. it is sever pain, radiating to left upper arm and is associated with sweating and vomiting. his ECG showes LBBB , but his 2
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Forums » Open clinical » Cardiology » thrombolysis in a patient with chest pain and LBBB on ECG
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thrombolysis in a patient with chest pain and LBBB on ECG
posted at 29/12/2011 5:24 PM GMT
on bmj.com
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Posts: 5
First: 29/12/2011 Last: 20/6/2012 |
A 50 years man comes to ER with acute chest pain of 6 hours duration. it is sever pain, radiating to left upper arm and is associated with sweating and vomiting. his ECG showes LBBB , but his 2 months old ECG also showes same LBBB, no change in fresh ECG. his troponin result showes high risk positive, diagnostic of acute infarction. should we thrombolyse this patient? |
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Re: thrombolysis in a patient with chest pain and LBBB on ECG
posted at 30/12/2011 8:39 AM GMT
on bmj.com
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Posts: 897
First: 17/6/2011 Last: 17/6/2013 |
I would say not - as I understand the guidelines for thrombolysis in the context of LBBB are for new or presumed new LBBB - the LBBB here is clearly old. These are the ACC/AHA guidelines below. http://circ.ahajournals.org/content/110/5/588.full |
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Re: thrombolysis in a patient with chest pain and LBBB on ECG
posted at 31/12/2011 3:22 AM GMT
on bmj.com
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Posts: 5
First: 29/12/2011 Last: 20/6/2012 |
thanx sadian for the response... if this patient develop st changes fulfilling Sgarbossa's criteria, then we will consider him having STEMI and will thrombolyse him. agreed? but going by guidlines this is not mention, they only note new and presumably new LBBB, which it is not, so then will you go for thrombolysis? |
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Re: thrombolysis in a patient with chest pain and LBBB on ECG
posted at 31/12/2011 12:25 PM GMT
on bmj.com
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Posts: 1
First: 31/12/2011 Last: 31/12/2011 |
in patients with left bundle branch block and chest pain is important to determine if this was previously documented LBBB. So that if it is old and suspected acute myocardial infarction is high, you should apply the criteria of Dr Sgarbosa to find thepossibility of an acute myocardial infarction who benefit from thrombolysis (STelevation). |
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Re: thrombolysis in a patient with chest pain and LBBB on ECG
posted at 31/12/2011 12:46 PM GMT
on bmj.com
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Posts: 6
First: 29/12/2011 Last: 31/12/2011 |
Maybe my criteria is outdated but If trop is positive, and chest pain....That is enough to assume MI.... you only need two of three. The ECG becomes obsolete.
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Re: thrombolysis in a patient with chest pain and LBBB on ECG
posted at 31/12/2011 1:58 PM GMT
on bmj.com
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Posts: 5
First: 31/12/2011 Last: 3/1/2012 |
The problem with pre-existing LBBB is that it makes reliable identification of ST elevation uncertain. Therefore you have to make a clinical decision based on other criteria - in this case it is pretty clear: go for PPCI if possible, thrombolysis (unless there are life-threatening contra-indications) otherwise. Just my humble opinion, of course. |
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Re: thrombolysis in a patient with chest pain and LBBB on ECG
posted at 31/12/2011 5:22 PM GMT
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
In this case I would not go for thrombolysis. It could be a Non-ST, with positive troponin levels, Acute Myocardial Infarction. There is no evidence that thrombolysis is indicated in those cases. If PCI is not available I would proceed with all the other measures for Non-ST acute MI. All Best, Joey
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Re: thrombolysis in a patient with chest pain and LBBB on ECG
posted at 31/12/2011 6:16 PM GMT
on bmj.com
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Posts: 897
First: 17/6/2011 Last: 17/6/2013 |
As you all say the diagnosis of STEMI in the context of LBBB is a challenge and there have been a number of modifications to the Sgarbossa rule as some studies suggest that using the original rule gives only a 50% chance of successful prediction. Guidelines will never cover every situation but my take on this patient would be that on the face of it he doesn't meet criteria for thrombolysis, if you have the facility and he has adverse features eg hypotension, ongoing pain etc he should go to the cath lab otherwise I would manage him as a NSTEMI. |
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Re: thrombolysis in a patient with chest pain and LBBB on ECG
posted at 2/1/2012 2:34 AM GMT
on bmj.com
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Posts: 5
First: 29/12/2011 Last: 20/6/2012 |
clinical features of MI and high troponin makes diagnosis of MI, now question is whether it is STEMI or NSTEMI, and in the setting of LBBB we can not say for sure and the sensitivity of sagarbosa criteria for diagnosis of MI in setting of LBBB is around 10 to 20%. so this is a difficult clinical situation and is not discussed properly in guidlines. i think we should thrombolyse the patient if he showes high risk features and give him benefit of doubt. |
Forums » Open clinical » Cardiology » thrombolysis in a patient with chest pain and LBBB on ECG
