title: Diagnosis of ventricular aneurysm and other severe segmental left ventricular dysfunction consequent to a myocardial infarction in the presence of right bundle branch block: ECG correlates of a positive diagnosis made via echocardiography and/or contrast ventriculography.
abstract: BACKGROUND
  A diagnostic ECG sign of a ventricular aneurysm (VA) consequent to a myocardial infarction (MI) in the presence of complete left bundle branch block was recently described, and consists of the presence of ST-segment elevation (+ST), instead of the expected ST-segment depression (-ST), in leads V4-6. Generally, complete right bundle branch block (RBBB) is associated with -ST in ECG leads V1-3. We hypothesized that stable +ST, instead of the expected -ST in leads V1-3 in patients with RBBB could be also diagnostic of a VA and other severe segmental left ventricular dysfunction (VA/SSD). Thus, this study was performed to explore the feasibility of using the ECG to diagnose a VA/SSD in the presence of RBBB, and to evaluate the determinants of such diagnosis.
  
  
  METHODS
  The frequency of +ST > or =1 mm in leads V1-3 was assessed in patients with RBBB, prior MI, and a VA/SSD diagnosed by echocardiography and/or contrast left cine-ventriculography. The ECG correlates for a positive or negative diagnosis of a VA/SSD were explored.
  
  
  RESULTS
  Out of 4197 files of our cohort of the Cardiology Clinic, RBBB was detected in 175 patients. Of these, 28 had an old MI, and had a VA/SSD diagnosed by > or =1 of noninvasive and/or invasive non-ECG tests. Twenty-one of these 28 patients had stable +ST in > or =1 of leads V1-3 (Group 1), and 7 did not (Group 2). Thus, the sensitivity of this ECG criterion for the diagnosis of VA/SSD was 75%, and the specificity was 100% in this highly selective group. VA/SSD in the septal and anterior myocardial regions was more frequent in the patients of Group 1, than in the patients of Group 2 (P = 0.03 and 0.02, correspondingly). The number of myocardial territories involved with the VA/SSD, or the ejection fraction were not different in the two groups (P = 0.65 and 0.55, correspondingly).
  
  
  CONCLUSIONS
  VA/SSD can be diagnosed in the presence of RBBB by the concordant to the QRS repolarization changes (+ST) in leads V1-3. Positivity of this ECG marker for VA/SSD correlates with involvement of the septal or anterior myocardial regions, and represents mechanistically a superimposition of primary repolarization alterations, overcoming the secondary such changes.
authors.affiliation: Mount Sinai School of Medicine, The New York University, New York, USA. madiasj@nychhc.org
authors.forename: John E
authors.initials: JE
authors.lastname: Madias
authors.forename: Ramin
authors.initials: R
authors.lastname: Ashtiani
authors.forename: Himanshu
authors.initials: H
authors.lastname: Agarwal
authors.forename: Virenjan K
authors.initials: VK
authors.lastname: Narayan
authors.forename: Moethu
authors.initials: M
authors.lastname: Win
authors.forename: Anjan
authors.initials: A
authors.lastname: Sinha
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002037:Bundle-Branch Block / Q000150:complications* / Q000503:physiopathology; D002932:Cineangiography; D004452:Echocardiography; D004562:Electrocardiography; D005260:Female; D006322:Heart Aneurysm / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000503:physiopathology; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology