Accident and Emergency Nursing (2007) 15, 56–61

Accident and
Emergency
Nursing

www.elsevierhealth.com/journals/aaen

Using the 12-lead ECG to diagnose acute

myocardial infarction in the presence of left
bundle branch block
Christine M. Spiers RGN, B.Sc. (Hons), M.Sc. (Cardiology)
(Principal Lecturer – Cardiology Nursing)

Institute of Nursing and Midwifery, University of Brighton, Westlain House,

Village Way, Falmer, Brighton BN1 9PH, United Kingdom

Received 27 June 2006; accepted 5 September 2006

KEYWORDS Summary The 12-lead ECG is a powerful clinical tool used to risk stratify patients
Acute myocardial presenting to the emergency department with chest pain. In particular the ECG is
infarction; used as the diagnostic tool to instigate reperfusion therapy in patients with acute
Left bundle branch coronary syndromes. The ECG features of acute myocardial infarction (AMI) may
block; be masked by the presence of left bundle branch block (LBBB) and the ECG may
ECG be difficult to interpret. Invariably this results in delays to the provision of throm-
bolysis to these patients despite the mounting body of evidence which demonstrates
that patients with AMI who present with LBBB have greater in-hospital mortality
than those who do not. Difficulties in interpreting the ECG in these patients can
therefore delay treatment and compromise their prognosis. The utility of the ECG
for the diagnosis of AMI in the presence of LBBB has recently received renewed
attention. ECG criteria have been identified which have a high association with
AMI in patients with LBBB and two ECG tools have been evaluated in clinical practice
which utilise these ECG criteria. The use of these simple algorithmic tools is recom-
mended for clinical practice.
c 2006 Elsevier Ltd. All rights reserved.

Introduction It is imperative that a rapid assessment of these pa-

The 12-lead electrocardiogram (ECG) is a powerful
tool for the clinical evaluation of patients present-
ing to the emergency department with chest pain.
E-mail address: C.M.Spiers@brighton.ac.uk
tients is made, as the primary objective in manag-
ing a patient with acute myocardial infarction (AMI)
is to offer early reperfusion therapy such as pri-
mary angioplasty or thrombolytic therapy. ST seg-
ment elevation on the 12-lead ECG is highly
specific for AMI and identifies patients who will
unequivocally benefit from reperfusion therapy


0965-2302/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aaen.2006.09.002
Using the 12-lead ECG to diagnose acute myocardial infarction
(Ambrosio and Mandorla, 2000). Numerous random-
ised controlled studies and meta-analyses demon-
strate that thrombolysis saves lives, limits infarct
size and reduced left ventricular dysfunction (GUS-
TO, 1993; Fibrinolytic Therapy Trialists FTT, 1994).
Additionally evidence continues to mount of the
benefits of primary angioplasty as the preferred
method of achieving reperfusion for patients with
AMI (Sgarbossa, 2000; De Belder, 2005). The practi-
tioner is faced with the need to make a rapid diag-
nosis from the clinical history and the 12-lead ECG.
Not only must the practitioner decide if the patient
is suffering an AMI, but also whether they would
benefit from urgent revascularisation (Rosner and
Brady, 1998). The ECG is pivotal in this decision
making process but the diagnosis is made more dif-
ficult in the presence of confounding ECG patterns
such as left bundle branch block (LBBB).
The fibrinolytic therapy trialist’s group (FTT,
1994) demonstrated that patients with AMI and
concomitant LBBB have an increased risk of poor
outcome but also demonstrated that patients with
AMI and BBB receive the greatest therapeutic ben-
efit from thrombolysis. Yet, these patients are also
less likely to receive thrombolysis due to difficul-
ties with diagnosis (Reuben and Mann, 2005).
Hence, these individuals are an important group
to identify because they have a higher baseline
mortality and derive the greatest benefit when of-
fered reperfusion therapy (Gallagher, 2001).
Acute myocardial infarction and left bundle
branch block
Diagnosis of AMI in the presence of LBBB is notori-
ously difficult and it is also a popular misapprehen-
sion that the 12-lead ECG is not useful for
identifying AMI in patients with LBBB (Sgarbossa,
2000). However the current Task Force Guidelines,
both in America and Europe recommend the pres-
ence of LBBB as one of the criteria for treating pa-
tients with thrombolytic therapy or primary
angioplasty (Antman et al., 2004; Van de Werf
et al., 2003). LBBB may be a pre-existing condition
or may occur acutely because of a proximal coro-
nary artery occlusion (Sokolove et al., 2000).
Various strategies have been employed by prac-
titioners over the years. A common approach is to
try to determine whether the LBBB is a new phe-
nomenon by seeking previous ECGs from old medi-
cal notes. There are a number of difficulties
inherent in this approach (Haywood, 2005). Firstly
if a patient has LBBB on admission but previous
ECGs do not show LBBB, can the new onset LBBB
be assumed to be due to AMI? Secondly, if the pa-
57
tient has LBBB, which was present on previous
ECGs, how does the practitioner differentiate be-
tween the absence or presence of a new infarction
in the presence of the LBBB? Lastly if the patient on
admission has LBBB but no previous notes are avail-
able for comparison, what ECG characteristics can
reliably distinguish whether the patient has an
acute infarction? (Haywood, 2005). These issues
have warranted much discussion and research in re-
cent years, as the problems highlighted are a fre-
quently encountered medical conundrum in the
emergency department.
A recent review of ‘thrombolysis nurses’ (Jones,
2005) suggests that nurses are involved in various
models of care in AMI from nurse initiated to nurse
led provision of thrombolysis both within the emer-
gency department and within coronary care. As
Loveridge (2004) states, never before has the deliv-
ery of a service (reperfusion therapy) been so
dependent upon nurses’ clinical decision making
skills and this decision making is predicated upon
confident 12-lead ECG appraisal. Hence, this is a
question which should vex nursing practitioners as
much as it has challenged our medical colleagues
in the last decade. The electrocardiographic diag-
nosis of AMI in the presence of LBBB may appear
difficult but the use of the ECG should not be dis-
counted; indeed careful examination of the LBBB
pattern may provide evidence of infarction if the
ECG interpreter is sufficiently knowledgeable.
LBBB on the 12-lead ECG
LBBB causes the heart to be depolarised in an
abnormal manner – with the left ventricle being
activated after the right ventricle rather than
simultaneously as occurs in normal conduction.
Because depolarisation is abnormal in LBBB, so is
repolarisation and thus LBBB results in a funda-
mental distortion of the ECG waveforms. In LBBB
the QRS duration is prolonged (>100 ms) and the
ST segment and T waves reflect a discordant pat-
tern. Discordancy refers to the ST segments and T
waves being opposite in polarity to the terminal
portion of the QRS complex (Wagner, 2001; Con-
over, 1996).
In LBBB depolarisation proceeds from right to
left which results in a broad negative QS complex
in V1 and a broadly positive R wave in V6 with a
late intrinsicoid deflection. Additionally the QRS
duration on all ECG leads will be greater than
100–120 ms and have a monophasic appearance
that is notched rather than smooth (Wagner,
2001). QS complexes will also be noted in the
right precordial and inferior leads. These findings
58
can be characteristically seen in the V1 and V6
leads (see Diagram 1).
The diagnosis of AMI rests heavily upon the
changes to the ST segment and to its deviation
from the isoelectric line. In LBBB the ST segment
is also abnormal and an understanding of these
ECG patterns will assist in the differentiation of
LBBB from AMI. In LBBB the ST segment and T
waves are discordant with the direction of the ter-
minal portion of the QRS complex. Rosner and Bra-
dy (1998) refer to this relationship as the ‘QRS
complex – ST segment/T wave axes discordance
or the rule of appropriate discordance’ (Rosner
and Brady, 1998, p 698). Thus any leads with a
broadly positive monophasic QRS complex will have
ST segment depression and/or T wave inversion in
the lead. Conversely any ECG with a broadly nega-
tive QS complex such as the right to mid precordial
Diagram 1 ECG changes in bundle branch blocks.
Figure 1 ECG 1 Classic example of LBBB demonstrating: a broad negative QS complex in V1, a broadly positive R wave
in V6 with a late intrisicoid deflection, QRS duration in all ECG leads is greater than 100–120 ms with a notched
monophasic appearance, ST/T wave discordancy is evident in all ECG leads.
C.M. Spiers
leads (V1–V3) will manifest a convex upward T
wave and ST segment elevation (see Fig. 1). This
may mimic the hyperacute T wave and ST segment
elevation seen in the acute phases of myocardial
infarction. Hence LBBB will manifest with ST seg-
ment and T wave discordance but loss of this nor-
mal discordant relationship in patients with LBBB
may point to an acute coronary occlusion such as
AMI (Rosner and Brady, 1998).
The potential for confusion is evident and the
need for careful inspection of the ECG in patients
presenting with chest pain and LBBB is imperative.
It would appear that physicians adopt two different
stances when dealing with this difficult group of pa-
tients. One approach is to suggest a broad-brush
approach of thrombolysis for all patients with chest
pain and LBBB with suspected AMI (Shilipak et al.,
2000; Gallagher, 2001). The more cautious practi-
tioners tend to err towards caution and are more
likely to withhold thrombolysis in this group.
Clearly, neither approach seems acceptable nor
evidence-based.
Towards an evidence based approach to
managing LBBB with AMI
The extent of the difficulty inherent in this clinical
scenario is evidenced by the number of ECG criteria
(more than 50 ECG signs) which have been pro-
posed over the last 50 years to detect infarction
in LBBB (Gallagher, 2001). Two tools may prove
helpful in the emergency department. The first
tool developed by Sgarbossa et al. (1996) was
derived from patients enrolled in the GUSTO
Using the 12-lead ECG to diagnose acute myocardial infarction 59

Table 1 Sgarbossa et al.’s (1996) clinical prediction tool (adapted)

Criterion Score
ST segment elevation >1 mm which is concordant with the QRS complex 5
ST segment depression >1 mm in V1, V2 or V3 leads 3
ST segment elevation >5 mm which is discordant with the QRS complex 2

Figure 2 ECG 2 Patient with suspected AMI and concomitant LBBB. Using Sgarbossa et al.’s (1996) clinical prediction
tool and Reuben and Mann’s (2005) algorithm, there is strong probability that AMI is present.

(1993) trial and proposes three specific ECG criteria
as indicators of AMI in LBBB (Table 1). This tool is
predicated upon the ST segment deviation in asso-
ciation with the QRS concordance. Sgarbossa et al.
(1996) identified three independent signs of AMI
with LBBB. The ECG criteria are ranked with a scor-
ing system based on the probability of the diagnosis
of AMI. A score of greater than three indicates
diagnosis of AMI has 90% specificity whereas a score
of two has only an 80% specificity (Sgarbossa et al.,
2001). This clinical tool has been tested by cardiol-
ogists and emergency physicians (Sokolove et al.,
2000) and has also been independently tested by
Edhouse et al. (1999), Li et al. (2000) and Kontos
et al. (2001). Furthermore recent findings from
the ASSENT 2 and 3 trials validated the utility of
Sgarbossa’s tool for diagnosing AMI in the presence
of LBBB (Al-Faleh et al., 2006). This tool may be
utilised in an emergency setting and will enable
this diagnostically challenging group of patients
to be ‘ruled in’ rather than ‘ruled out’ for treat-
ment (see Fig. 2).
The second tool developed by Reuben and Mann
(2005) is derived from Sgarbossa et al.’s (1996)
clinical prediction tool. Reuben and Mann (2005)
have however sought to reword and simplify Sgar-
bossa et al.’s criteria, explicitly removing refer-
ence to concordancy and discordancy of the ST

Table 2 Reuben and Mann’s (2005) algorithm (adapted)

Patient with chest pain and LBBB and any of the following criteria
1. ST segment elevation >1 mm in leads where the QRS complex is predominantly positive
2. ST segment elevation >5 mm in leads where the QRS complex is predominantly negative (usually leads V1–V3 in LBBB)
3. ST segment depression >1 mm in leads V1, V2 or V3

'Thrombolyse if there are no contraindications

60
segment and avoiding the scoring system suggested
by Sgarbossa et al. (1996). It is believed that these
phrases may be confusing and difficult to apply in
practice. They have redesigned Sgarbossa et al.’s
(1996) criteria into a flow treatment algorithm for
practical decision making purposes (Table 2). This
algorithm has only been tested with a small number
of clinicians and they acknowledge the importance
of further research. However this tool is derived
from a credible source and may have utility in
emergency departments where decision-making
needs to be fast and accurate. This algorithm is
simple and can be easily applied.
Using the tools in practice
ECG 2 shows a patient with suspected AMI and con-
comitant LBBB. Using Sgarbossa et al.’s (1996) clin-
ical prediction tool, there is strong evidence of the
presence of AMI (see Table 1). There is 1 mm of ST
segment elevation in leads V5 and V6 (score 5) and
there is between 5 and 9 mm of ST segment eleva-
tion in leads V2–V4 (score 3). Using Reuben and
Mann’s algorithm (Table 2) two of the three criteria
are also met.
Conclusion
The ECG remains the most widely used clinical
assessment tool to evaluate patients presenting
to the emergency department with chest pain and
suspected AMI. Patients with AMI and concomitant
LBBB have increased risk of poor outcome and yet
these patients are also less likely to receive throm-
bolysis or other revascularisation treatments due
to difficulties with diagnosis. In addition, because
of difficulties with diagnosis, these patients may
find that their treatment is delayed, and delays
to treatment result in loss of functioning myocar-
dium. The ECG abnormalities of AMI may be
masked by the pattern of intraventricular conduc-
tion encountered in LBBB notably in the changes
to the directional concordance of the ST segment
with the QRS complex. In the past practitioners be-
lieved that recognition of AMI in the presence of
new or pre-existing LBBB was impossible. With
the advent of revascularisation techniques how-
ever, the need to establish or refute the diagnosis
of AMI in such patients has become a priority.
The presence of LBBB on the presenting ECG is an
accepted criterion for the implementation of
reperfusion therapy, yet difficulty in interpreting
the ECG in this group of patients can compromise
their treatment plan. The Sgarbossa et al.’s
C.M. Spiers
(1996) criteria provide a tool to identify AMI in this
group of high-risk patients and Reuben and Mann’s
(2005) simplified interpretation of these criteria
may enable practitioners to make therapeutic deci-
sions in a more timely fashion. The implementation
of diagnostic criteria for this challenging group of
patients is highly recommended and could easily
be incorporated into thrombolysis protocols in ED
departments.
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