T–inversion (Discordance with terminal deflection) ST –displacement from isoelectric line (Discordance with terminal deflection) P/S: But this is NO ST-displacement in RBBB
Normal BBB should obey this “normal condition”
So when BBB don’t obey this “normal condition” there is MI !
SGARBOSSA’s CRITERIA by Elena B. Sgarbossa
Modified* Sgarbossa’s Criteria
Concordant STE > 1 mm
2. Concordant STD > 1 mm
in V1, V2, or V3
3. Discordant STE > 5mm
*Discordant STE > ¼ QRS
Now let’s put what we learn into practice!
Now let’s make it harder. Try to determine the presence of MI and also it’s location.
The patient is an elderly female with a known history of LBBB who presented to the emergency ward with S.O.B.
She did in fact rule in for a myocardial infarction with a CK of 700 and 21% MB fraction.
To use the rules of concordance in determination of the presence of MI seems easy, but not as easy as we think.
Final Case Middle-aged man admitted with recent chest pain. ECG with the attachment.
7 Hint: There are 7 abnormalities
1. Borderline STC 2. LBBB 3. 2° AV block (5:4 & 4:3 patterns) 4. Single PVC 5. Acute/evolving infero-lateral MI 6. Borderline low QRS voltage 7. Left atrial abnormality.
Cardiac cath. in this patient revealed severe 3 vessel coronary disease with evidence of thrombus in the right posterolateral branch. Left ventriculography showed a reduced left ventricle ejection fraction of 32% with inf./post. & apical/lat. wall motion abnormalities.
Additional comments: Mobitz type I (AV Wenckebach) block is not uncommon with acute inferior MI. Usually this condition disturbance is transient with inferior MI and does not require temporary or permanent pacing.
A Word of Caution NB! This criteria is useful, but final diagnosis of MI should always be confirmed by CE elevation and angiography (if possible).
Thank you for your attention!
Elevated troponin levels have been documented in other disease states and situations that are not associated with atherosclerotic epicardial coronary artery disease, including the following: * Pacing, automated implantable cardioverter-defibrillator * Tachyarrhythmias * Hypertension * Myocarditis * Myocardial contusion * Acute and chronic congestive heart failure * Cardiac surgery * Renal failure * Pulmonary embolism * Subarachnoid hemorrhage * Sepsis * Hypothyroidism * Shock