Right bundle-branch block in anterior acute myocardial infarction in the coronary intervention era: Acute angiographic findings and prognosis

doi:10.1016/j.ijcard.2006.02.010

International Journal of Cardiology

Volume 116, Issue 1, 2 March 2007, Pages 57-61

https://doi.org/10.1016/j.ijcard.2006.02.010 Get rights and content

Abstract

Background

Previous studies in the prethrombolytic or thrombolytic era have reported that right bundle-branch block (RBBB) is associated with poor clinical outcome in patients with acute myocardial infarction (AMI).

Methods and Results

The purpose of this study was to examine the relations between RBBB and angiographic findings or clinical outcomes in patients with AMI in the coronary intervention era. A total of 430 patients with a first anterior AMI who underwent coronary angiography within 12 h after the onset were enrolled in this study. Seventy-one patients (17%) had RBBB documented during their hospital stay. RBBB was documented on admission in 35 patients. Patients with RBBB were older (p < 0.01) and had prodromal angina less frequently (p = 0.03) than those without. On the initial angiograms, patients with RBBB had an occluded left anterior descending artery (p < 0.01) and multivessel disease (p = 0.01) more frequently than those without. Thirty-day mortality rate was significantly higher in patients with RBBB than in those without (14.0% vs 1.9%, p < 0.01). Multiple logistic-regression analysis demonstrated that RBBB (odds ratio 5.89, p < 0.01) and multivessel disease (odds ratio 4.36, p = 0.01) were independent predictors of 30-day mortality.

Conclusions

Our data suggested that RBBB was still associated with poor clinical outcome in patients with anterior AMI even in the coronary intervention era.

Introduction

Previous studies in the prethrombolytic era have reported that right bundle-branch block (RBBB) occurs in 3–29% of patients with acute myocardial infarction (AMI) [1], [2], [3], [4], [5], [6], [7], [8]. Because of the blood supply of the conduction system, patients with anterior AMI and RBBB usually have large infarct sizes that are often accompanied by heart failure, ventricular arrhythmia or mortality. Although the introduction of thrombolytic therapy has affected the occurrence and resolution of RBBB [7], [8], [9], reduced mortality rate and improved left ventricular function in patients with AMI [10], [11], [12], RBBB still identified a subset of patients with high mortality rate in the thrombolytic era [13], [14], [15], [16]. Because of lack of angiography before thrombolytic therapy, it remained unclear whether RBBB was dependent on the perfusion status of the infarct-related artery. To assess this issue, we examined the relation between RBBB and acute angiographic findings in patients with anterior AMI.

Recent randomized trials indicated that coronary intervention might be superior to thrombolytic therapy with regard to the early and late clinical outcomes [17], [18]. Thus, it is probable that the introduction of coronary intervention may have changed implications of RBBB in patients with anterior AMI. To assess this issue, we also examined the relations between RBBB and 30-day mortality or left ventricular function.

Section snippets

Study population

Between January 1990 and December 2003, 430 patients with a first anterior AMI underwent coronary angiography within 12 h after the onset of chest pain. Anterior AMI was diagnosed by (1) chest pain consistent with ongoing myocardial ischemia persisting ≥ 30 min; (2) increase in serum creatine kinase to twice the normal upper value; and (3) presence of a culprit lesion in the left anterior descending artery. Serum creatine kinase was measured every 3 h for > 24 h, and peak creatine kinase value

Incidence of RBBB

This study group included 430 patients. Of 430 patients, 71 (17%) had RBBB documented during their hospital stay. RBBB was documented on admission in 35 patients. It was persistent in 23 patients, and transient in 48 patients. Of 23 persistent RBBBs, 11 were new, 6 were old and the remaining 6 were indeterminate.

Baseline characteristics

Patients with RBBB were older (p < 0.01) and had prodromal angina less frequently (p = 0.03) than those without. There was no significant difference in hypertension, diabetes, time to

Present findings

The major findings of this study were (1) RBBB was associated with older age, less prodromal angina and less spontaneous anterograde flow; (2) RBBB was a strong predictor of 30-day mortality even in the percutaneous coronary intervention era; and (3) RBBB was associated with poor left ventricular function during early phase of anterior AMI.

RBBB in the thrombolytic era

Previous studies have shown that RBBB still identifies a subset of patients with high mortality rate in the thrombolytic era [13], [14], [15]. Although

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Cited by (25)

When the ECG Tells the Story, But It is Not Heard
2023, Annals of Emergency Medicine
Acute myocardial infarction with right bundle branch block at presentation: Prevalence and mortality
2021, Journal of Electrocardiology
Citation Excerpt :
In our study, as in other publications [11], no difference in the incidence of complete atrioventricular block was documented. Regarding the culprit artery in AMI, evidence suggests an association between the presence of RBBB and the involvement of the left anterior descending coronary artery [9,19,23]. In the publication of Arslan et al., in patients with anterior STEMI, the lesion in the proximal left anterior descending coronary artery was more frequent in the RBBB group than in the control group with normal intraventricular conduction (62% vs. 27% p: 0.03) [4].
Right Bundle Branch Block (RBBB) has been reported in 5–11% of the acute myocardial infarctions (AMI), and it could be the only electrocardiographic abnormality in this group of patients. We investigated the mortality in patients with AMI and the presence of RBBB.
A retrospective cohort study was conducted between January 2011 to December 2017 at a university hospital in Bogotá, Colombia. Records were obtained from all patients who presented at the emergency department with AMI; patients with early transfer and incomplete follow-up were excluded.
1015 patients were included, the mean age was 66 years, 67% of the patients were men, and 38% had STEMI. RBBB was documented in 8% of patients and LBBB in 4% of patients. In-hospital mortality was higher in the group of patients with RBBB vs. patients without RBBB (8.64% vs. 3.74%, p = 0.034). The percentage of patients with Killip ≥II classification was higher in patients with new RBBB vs. patients with old or unknown duration RBBB (23% vs. 13%, p = 0.216).
In patients with AMI, the presence of RBBB was associated with a statistically significant increase of in-hospital mortality.
In Hospital Outcomes of Patients With Right Bundle Branch Block and Anterior Wall ST-Segment Elevation Myocardial Infarction (From a Nationwide Study Using the National Inpatient Sample)
2021, American Journal of Cardiology
Previous studies have reported worse outcomes for patients with right bundle branch block (RBBB) complicating acute ST-segment elevation myocardial infarction (STEMI). There is a paucity of data examining outcomes with RBBB and STEMI in contemporary large-scale studies. This study aims to explore the outcomes of patients with anterior wall STEMI (AW-STEMI) and RBBB. Using ICD-9 codes, we queried the National Inpatient Sample of 1999 to 2014 to identify AW-STEMI admissions and stratified them for the presence of RBBB. Primary outcome was in-hospital mortality within 30 days. Secondary outcomes included acute heart failure, complete heart block, and permanent pacemaker implantation. Cox-proportional logistic regression models were used to determine the hazard ratios of the primary outcome and secondary outcomes and interventions. Among 1,075,875 weighted anterior wall STEMI (AW-STEMI) admissions, 19,153 (1.8%) had RBBB. Compared with patients without RBBB, mortality was significantly higher for patients with RBBB (9.2% vs 15.3%; p <0.0001). RBBB in the setting of AW-STEMI was associated with a 66% increased risk of 30-day in-hospital mortality (hazard ratios [HR], 1.66; 95% confidence interval [CI], 1.52 to1.81; p <0.0001) and a higher likelihood of acute heart failure (HR, 1.37; 95% CI, 1.29 to 1.45; p <0.0001), complete heart block (HR, 2.90; 95% CI, 2.64 to 3.18; p <0.0001) and utilization of a permanent pacemaker (HR, 2.51; 95% CI, 1.89 to 3.35; p <0.0001). In conclusion, the presence of RBBB in the setting of an AW-STEMI is a significant independent predictor of a poor prognosis, including a higher rate of acute heart failure, complete heart block, need for a permanent pacemaker, and a higher 30-day in-hospital mortality.
Electrocardiographic Predictors of Mortality in Acute Anterior Wall Myocardial Infarction With Right Bundle Branch Block and Right Precordial Q-Waves (qRBBB)
2020, Canadian Journal of Cardiology
Published data on the clinical, electrocardiographic, and angiographic profile of acute anterior-wall ST-elevation myocardial infarction (STEMI) with right bundle branch block with q in leads V1, V2 (qRBBB) are scarce. The aim of this study was to estimate the incidence of short-term mortality and in-hospital complications in acute qRBBB STEMI and identify the electrocardiographic (ECG) predictors of a poor outcome.
We conducted a single-centre retrospective study among the patients with acute anterior-wall STEMI and qRBBB pattern on ECG. All relevant clinical and treatment data were collected from the electronic medical records. All the ECGs taken during the index hospitalization were subjected to detailed analysis.
Among the 272 qRBBB patients included in the study, 64% had thrombolysis in myocardial infarction (TIMI) risk score of ≥6, and 41% were in Killip class III or IV at the time of presentation. The in-hospital mortality rate was 42.6%. There was a high incidence of ventricular tachyarrhythmias (12%), complete heart block (13%), heart failure (69%), and cardiogenic shock (52%). Extreme deviation of mean QRS axis to the right (180 to 269 degrees) in the baseline ECG was associated with high in-hospital mortality (odds ratio: 13.43; 95% confidence interval: 1.48-122.03; P = 0.021).
Acute qRBBB myocardial infarction is a sinister form of acute coronary syndrome that entails high in-hospital mortality and morbidity, necessitating early recognition and prompt institution of reperfusion therapy. Extreme deviation of QRS axis to the right (180 to 269 degrees) is a significant electrocardiographic predictor of in-hospital mortality.
Très peu de données ont été publiées sur le profil clinique, électrocardiographique et angiographique de l’infarctus antérieur aigu du myocarde avec élévation du segment ST associé à un bloc de branche droit et à la présence d’ondes Q dans les dérivations V1 et V2 (BBDQ). Cette étude visait à estimer la mortalité à court terme et les complications hospitalières dans les cas d’infarctus antérieur aigu du myocarde avec élévation du segment ST associé à un BBDQ et à cerner les prédicteurs électrocardiographiques de résultats défavorables.
Nous avons mené une étude rétrospective monocentrique regroupant des patients qui ont subi un infarctus antérieur aigu du myocarde avec élévation du segment ST associé à un BBDQ à l’électrocardiogramme (ECG). Toutes les données pertinentes sur la situation clinique et le traitement ont été tirées des dossiers médicaux électroniques. Tous les ECG obtenus au cours de l’hospitalisation de référence ont été l’objet d’une analyse détaillée.
Parmi les 272 patients présentant un BBDQ inclus dans l’étude, 64 % avaient obtenu un score de risque TIMI (thrombolyse de l’infarctus du myocarde) égal ou supérieur à 6 et 41 % se situaient au stade III ou IV de la classification de Killip lors de l’examen initial. Le taux de mortalité hospitalière s’établissait à 42,6 %. Une incidence élevée de tachyarythmie ventriculaire (12 %), de bloc cardiaque complet (13 %), d’insuffisance cardiaque (69 %) et de choc cardiogène (52 %) a été notée. Une déviation droite extrême de l’axe moyen du complexe QRS (de 180 à 269°) à l’ECG initial était associée à un taux élevé de mortalité hospitalière (rapport de cotes : 13,43; intervalle de confiance à 95 % : 1,48-122,03; p = 0,021).
L’infarctus aigu du myocarde associé à un BBDQ est une forme inquiétante de syndrome coronarien aigu présentant un taux élevé de mortalité et de morbidité hospitalières. Il doit être diagnostiqué rapidement et nécessite un traitement de reperfusion dans les plus brefs délais. Une déviation droite extrême de l’axe du complexe QRS (de 180 à 269°) constitue un important prédicteur électrocardiographique de mortalité hospitalière.
Prognostic impact of bundle branch block after acute coronary syndrome. Does it matter if it is left of right?
2019, IJC Heart and Vasculature
Citation Excerpt :
However, for RBBB, evidence is less robust, with fewer available clinical studies and a lower level of evidence. The prevalence of RBBB in the context of ACS is 6–10% [6–12]. In fibrinolysis era, both BBB types had high in-hospital mortality, of around 15–20%, much higher when compared to STEMI patients or other ACS with normal QRS duration [6–8].
In previous guidelines, acute coronary syndromes (ACS) with new or presumably new left bundle branch block (LBBB) were an indication for reperfusion treatment, preferably with primary angioplasty. Recent guidelines also included the presence of right bundle branch block (RBBB) in this recommendation. It was our objective to evaluate in a population of patients with ACS the differential impact of RBBB and LBBB in prognosis.
Consecutive patients included prospectively in a single-centre registry of ACS were included in the study. Patients were analyzed according to baseline ECG characteristics (normal QRS, LBBB or RBBB). Primary outcome was all-cause mortality at one-year follow-up. We used Cox-proportional hazards models to assess the predictive value for the primary outcome.
A total of 3990 patients were included in, with a mean age of 64 (13) years, 72% males, 3.4% with LBBB and 4.3% with RBBB. Patients with BBB were older, with more previous history of myocardial infarction and coronary revascularization and higher prevalence of cardiovascular risk factors (except smoking). Medical treatment was similar but they were less often submitted to angioplasty. In univariate analysis, BBB patients had worst outcome (Log-rank, p < 0.001), but similar in LBBB and RBBB (Log-rank, p = 0.597). In multivariate analysis, only RBBB (HR 1.66, 95%CI 1.14–2.40, p = 0.007) is an independent predictor of all-cause mortality.
Patients with BBB have worst outcome after an ACS, particularly with RBBB. For that reason, we should pay special attention and treat these patients as aggressively as patients with normal QRS duration or LBBB.
Poor R-wave progression and myocardial infarct size after anterior myocardial infarction in the coronary intervention era
2015, IJC Heart and Vasculature
Citation Excerpt :
The study population consisted of 53 patients with prior anterior MI beyond at least more than 6 months after the onset and 20 age- and sex-matched patients without. Anterior MI was diagnosed by chest pain consistent with ongoing myocardial ischemia for more than 30 min, elevation of serum creatine kinase to more than twice the normal upper limit and a culprit lesion of the proximal left anterior descending artery on angiography [9]. All patients underwent stent deployment during early period, and underwent ECG, myocardial perfusion SPECT and echocardiography beyond at least more than 6 months after MI.
Regeneration of R-wave or disappearance of Q-wave sometimes occurs after myocardial infarction (MI) especially in the coronary intervention era. We assessed the impact of poor R-wave progression (PRWP) or residual R-wave in precordial leads on myocardial infarct size in patients with prior anterior MI treated with coronary intervention.
Fifty-three patients with prior anterior MI and 20 age- and sex-matched patients without underwent electrocardiogram (ECG), myocardial perfusion single photon emission tomography (SPECT) and echocardiography. Poor R-wave progression (PRWP) was defined as RV3 ≤ 3 mm.
R-wave was significantly lower in all precordial leads in patients with prior anterior MI than those without. Among 53 patients with prior anterior MI, 33 patients had PRWP, and the remaining 20 patients did not. Patients with PRWP had larger sum of defect score (17.5 ± 8.6 vs 7.6 ± 10.3, p < 0.001) and lower left ventricular ejection fraction (LVEF) (46.1 ± 9.8% vs 55.2 ± 12.9%, p < 0.01) than those without. The sum of R-wave in lead V1 to V6 inversely correlated with the sum of defect score (r = − 0.56, p < 0.001), and positively correlated with LVEF (r = 0.45, p < 0.001).
Our data suggested that residual R-wave during the follow-up period reflected myocardial infarct size and left ventricular systolic function well in patients with prior anterior MI treated with coronary intervention.

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Right bundle-branch block in anterior acute myocardial infarction in the coronary intervention era: Acute angiographic findings and prognosis

Abstract

Background

Methods and Results

Conclusions

Introduction

Section snippets

Study population

Incidence of RBBB

Baseline characteristics

Present findings

RBBB in the thrombolytic era

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Complete bundle-branch block complication in acute myocardial infarction

N Engl J Med

Right bundle-branch block and left axis deviation in acute myocardial infarction

Br Heart J

Clinical and anatomic implication of intraventricular conduction block in acute myocardial infarction

Circulation

Bundle-branch block complicating acute myocardial infarction

JAMA

Ventricular conduction blocks and sudden death during acute myocardial infarction: potential indication for pacing

N Engl J Med

The clinical significance of bundle branch block complicating acute myocardial infarction: I. Clinical characteristics, hospital mortality, and 1-year follow-up

Circulation