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CLINICAL RESEARCH: ACUTE ISCHEMIA OR INFARCTION

Patients With Prolonged Ischemic Chest Pain and Presumed-New Left Bundle Branch Block Have Heterogeneous Outcomes Depending on the Presence of ST-Segment Changes

Cheuk-Kit Wong, MD, FACC^_*,, John K. French, MB, PhD, FACC^_*, Philip E.G. Aylward, MD, FACC, Ralph A.H. Stewart, MD, FACC^_*, Wanzhen Gao, PhD^_*, Paul W. Armstrong, MD, FACC, Frans J.J. Van De Werf, MD, FACC^||, R. John Simes, MD^¶, O. Christopher Raffel, MB^_*, Christopher B. Granger, MD, FACC^#, Robert M. Califf, MD, FACC^#, Harvey D. White, DSc, FACC^_*,_* for the HERO-2 Trial Investigators

^_* Cardiovascular Research Unit, Green Lane Hospital, Auckland, New Zealand
Department of Medical and Surgical Sciences, University of Otago, Dunedin, New Zealand
Cardiology Department, Flinders Medical Centre, Adelaide, South Australia
Department of Medicine, University of Alberta, Edmonton, Canada
^|| Department of Cardiology, Gasthuisberg University Hospital, Leuven, Belgium
^¶ National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
^# Duke Clinical Research Institute, Durham, North Carolina.

Manuscript received August 18, 2004; revised manuscript received February 2, 2005, accepted February 8, 2005.

^_* Reprint requests and correspondence: Honorary Professor Harvey White, Cardiology Department, Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, Auckland 1030, New Zealand. (Email: harveyw{at}adhb.govt.nz).

OBJECTIVES: The purpose of this research was to examine the prognostic value of ST-segment changes (concordant ST-segment elevation and/or precordial V₁ to V₃ ST-segment depression) during presumed-new left bundle branch block (LBBB) in patients receiving fibrinolytic therapy.

BACKGROUND: These patients are often considered high-risk, but their outcome is not well-defined.

METHODS: The Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial compared bivalirudin with heparin in patients receiving streptokinase for ST-segment elevation or presumed-new LBBB. Each patient with LBBB was matched with a control (with normal intraventricular conduction) for age, gender, pulse rate, systolic blood pressure, Killip class, and region.

RESULTS: A total of 300 patients had LBBB (92 with and 208 without ST-segment changes) and 15,340 had normal conduction. Acute myocardial infarction (AMI) occurred in 80.7% of LBBB patients and 88.7% of controls (p = 0.006). ST-segment changes were specific (96.6%) but not sensitive (37.8%) for enzymatic diagnosis of AMI. Mortality at 30 days was similar in LBBB patients with ST-segment changes (21.7%) and controls (25.0%, p = 0.563), but lower in LBBB patients without ST-segment changes than in controls (13.5% vs. 21.6%, p = 0.022). In the whole HERO-2 cohort, the LBBB patients with ST-segment changes had higher mortality than patients with normal conduction (odds ratio [OR] 1.37, 95% confidence interval [CI] 0.78 to 2.42). The LBBB patients without ST-segment changes had lower mortality than patients with normal conduction (OR 0.52, 95% CI 0.33 to 0.80).

CONCLUSIONS: ST-segment changes during LBBB are specific for the diagnosis of AMI and predict 30-day mortality; LBBB patients without ST-segment changes have lower adjusted 30-day mortality than those with normal conduction. Trials are required to determine the best treatment for high-risk and low-risk patients with LBBB.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CI = confidence interval   CK = creatine kinase   GUSTO = Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries   HERO = Hirulog and Early Reperfusion or Occlusion   LBBB = left bundle branch block   OR = odds ratio   RBBB = right bundle branch block   ULN = upper limit of normal

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