title: 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.
abstract: OBJECTIVE
  Sgarbossa's rule, proposed for the diagnosis of acute myocardial infarction in the presence of left bundle branch block, has had suboptimal diagnostic utility. We hypothesize that a revised rule, in which the third Sgarbossa component (excessively discordant ST-segment elevation as defined by ≥5 mm of ST-segment elevation in the setting of a negative QRS) is replaced by one defined proportionally by ST-segment elevation to S-wave depth (ST/S ratio), will have better diagnostic utility for ST-segment elevation myocardial infarction (STEMI) equivalent, using documented coronary occlusion on angiography as reference standard.
  
  
  METHODS
  We collected admission ECGs for all patients with an acutely occluded coronary artery and left bundle branch block at 3 institutions. The ECGs of emergency department patients with chest pain or dyspnea and left bundle branch block, but without coronary occlusion, were used as controls. The R or S wave, whichever was most prominent, and ST segments, relative to the PR segment, were measured to the nearest 0.5 mm. The ST/S ratio was calculated for each lead that has both discordant ST deviation of greater than or equal to 1 mm and an R or S wave of opposite polarity; others were set to 0. The cut point for the most negative ST/S ratio with at least 90% specificity was determined. The revised rule is unweighted, requiring just 1 of 3 criteria. Diagnostic utilities of the original and revised Sgarbossa rules were computed and compared. McNemar's test was used to compare sensitivities and specificities.
  
  
  RESULTS
  The study and control groups included 33 and 129 ECGs, respectively. The cut point selected for relative discordant ST-segment elevation was -0.25. Excessive absolute discordant ST-segment elevation of 5 mm was present in at least one lead in 30% of ECGs in patients with confirmed coronary occlusion versus 9% of the control group, whereas excessive relative discordant ST-segment elevation less than -0.25 was present in 79% vs. 9% [corrected].Sensitivity of the revised rule in which ST-segment elevation with an ST/S ratio less than or equal to -0.25 replaces ST-segment elevation greater than or equal to 5 mm was significantly greater than either the weighted (P<.001) or unweighted (P=.008) Sgarbossa rule: 91% (95% confidence interval [CI] 76% to 98%) versus 52% (95% CI 34% to 69%) versus 67% (95% CI 48% to 82%). Specificity of the revised rule was lower than that of the weighted rule (P=.002) and similar to that of the unweighted rule (P=1.0): 90% (95% CI 83% to 95%) versus 98% (95% CI 93% to 100%) versus 90% (95% CI 83% to 95%). Positive and negative likelihood ratios for the revised rule were 9.0 (95% CI 8.0 to 10) and 0.1 (95% CI 0.03 to 0.3). The revised rule was significantly more accurate than both the weighted (16% difference; 95% CI 5% to 27%) and unweighted (12% difference; 95% CI 2% to 22%) Sgarbossa rules.
  
  
  CONCLUSIONS
  Replacement of the absolute ST-elevation measurement of greater than or equal to 5 mm in the third component of the Sgarbossa rule with an ST/S ratio less than -0.25 greatly improves diagnostic utility of the rule for STEMI. An unweighted rule using this criterion resulted in excellent prediction for acute coronary occlusion.
authors.affiliation: Hennepin County Medical Center, Minneapolis, MN, USA. smith253@umn.edu
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Smith
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Dodd
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Henry
authors.forename: David M
authors.initials: DM
authors.lastname: Dvorak
authors.forename: Lesly A
authors.initials: LA
authors.lastname: Pearce
mesh_terms: D002037:Bundle-Branch Block / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D016022:Case-Control Studies; D054059:Coronary Occlusion / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology; D003661:Decision Support Techniques; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D006801:Humans; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology; D012680:Sensitivity and Specificity