## Saturday, July 26, 2014

### Is there excessively discordant ST Elevation in this ECG with Left Bundle Branch Block?

A patient complained of atypical chest pain and cough.  Here is his ECG:
 There is sinus tachycardia at a rate of 120 with LBBB.  By the way, this is a New LBBB.  Where do we measure the ST elevation in the right precordial leads????  See below.

 It is easy to find the J-point in lead V1, and all other J-points beneath it are simultaneous.  So I drew a line from the J-point directly down.  The intersection of the left side of this line with the tracing in leads V2 and V3 is the J-point.  It is 8 mm in V2 and 14 mm in V3.

8 and 14 mm of ST Elevation!!  In a patient with new LBBB!

Surely this must be an acute anterior STEMI, no?

Again, the ECG is always proportional, with repolarization proportional to depolarization.  In this case, the S-wave in V2 is 42 mm and the S-wave in V3 is well over 60 mm (it goes far off the page).

Ratios:
V2: 8/42 is less than 0.20
V3: 14/(greater than 70) is less than 0.20

We found that a ratio greater than or equal to 0.25 was very sensitive and specific for coronary occlusion.  A value greater than 0.20 is almost always occlusion as well.

But a normal maximum ratio from V1-V4 is about 0.11, so I think any ratio greater than 0.15 should be scrutinized, with serial ECGs/echo.

So the ratios are not excessive, but they are borderline.  In this case, there was no STEMI, and there was indeed no MI in this case.

Another point: in LBBB, an increased heart rate will often increase the ST elevation.  So before coming to conclusions, it is wise to lower the heart rate.  In this case, the patient was dehydrated, so he received some fluids and his heart rate came down to about 95:
 See the annotated EKG below

 Now there is: V2: 5.5 mm of STE with a 35 mm S-wave (ratio = 0.16) V3: 7.0 mm of STE with a 57 mm S-wave (ratio = 0.12)

So BOTH the QRS voltage and the ST elevation voltage have come down, but the ratio has come down even more.

You may object: "the ST elevation ratio is dynamic!  There must have been a transient STEMI!!"

But this is not the case: tachycardia gives false + ST elevation in LBBB.  In this case, the ST elevation ratio is under the threshold of 0.20 - 0.25 both before AND after the heart rate is brought down.

Lessons:

1. Tachycardia elevates the ST segments in Left Bundle Branch Block
2. The significance of ST elevation depends on its proportion to the QRS
3. Finding the J-point in any one lead may be difficult.  Use the other leads to draw a vertical line to find it!

1. Sir, is it wise to start thrombolytic therapy in lbbb patients with pain as no method 100% confirm or reject mi.

2. Dr. Gupta,
I would not give thrombolytics to this patient! Here is a good guide to reperfusion therapy in LBBB:
https://www.mcfarlandclinic.com/file.cfm/media/cms/The_left_bundlebranch_block_puzzle__D98A0CC95BA67.pdf
Steve Smith

3. Dear Dr Smith,
How do you calculate the ratio (in simple terms, I'm terrible at maths)?
In our service we convey to the cath lab new onset LBBB with cardiac-sounding chest pain. Is this standard practice?
Thanks for your time & this great blog!
Claire S

1. Claire,
It really does not take math, just simple arithmetic: division. Find the ST elevation at the J-point (see images) and divide by the preceding S-wave. If the result is > 0.25, then it is excessive discordance and it is STEMI. See this paper which has an algorithm: https://www.mcfarlandclinic.com/file.cfm/media/cms/The_left_bundlebranch_block_puzzle__D98A0CC95BA67.pdf

Glad you are benefiting from the blog!

Steve Smith

2. Sgarbossa (I know, I know) allocated 2 points to >5mm discordant ST elevation. But, her analysis gave 90% specificity to >2 points. So even by the original diagnostic criteria, this would not have been called a STEMI.

4. In 1st ecg in lead V6 there is S wave why it disappeared in2nd ecg

1. good question. simply lead placement, I think

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