Clinical and angiographic importance of right bundle branch block in the setting of acute anterior myocardial infarction/Akut anterior miyokard enfarktusunde sag dal blogunun klinik ve anjiyografik onemi.ABSTRACT
Objective: To investigate functional status of patients (Killip class), left ventricular contractility contractility /con·trac·til·i·ty/ (kon?trak-til´i-te) capacity for becoming shorter in response to a suitable stimulus.
a capacity for becoming short in response to suitable stimulus. , an giographic anatomy and severity of coronary lesions in patients with and without right bundle branch block right bundle branch block Cardiology A condition in which the electrical impulse from the bundle of His to the ventricles is delayed or fails to conduct along the right bundle branch, resulting in right ventricular depolarization by cell-to-cell conduction (RBBB RBBB right bundle branch block; see bundle branch block, under block.
right bundle branch block
RBBB Right bundle-branch block, see there ) in the setting of anterior myocardial infarction myocardial infarction: see under infarction. (MI).
Methods: Patients who admitted to coronary care unit coronary care unit
Abbr. CCU A hospital unit that is specially equipped to treat and monitor patients with serious heart conditions, such as coronary thrombosis. with the diagnosis of acute anterior MI between 1999 and 2005 were retrospectively searched from our database. Out of 792 patients, 37 had RBBB (RBBB group) either at admission or in the course of anterior MI. Forty patients who developed no intraventricular conduction intraventricular conduction
The conduction of the cardiac impulse through the ventricular muscle tissue. Also called ventricular conduction. defect during the course of anterior MI with the same demographic characteristics were selected as the control group.
Results: Out of 37 patients, 30 had RBBB on admission and 7 developed RBBB in the course of acute MI. Left anterior descending artery (LAD) proximal lesion was more commonly detected in the RBBB group [23 (62.2%) vs. 11 (27.5%) patients, p=0.003]. Left ventricular ejection fraction ejection fraction
The blood present in the ventricle at the end of diastole and expelled during the contraction of the heart.
Ejection fraction was lower (33.0 [+ or -] 4.2% vs 36.7 [+ or -] 4.9%, p=0.003) and end-systolic volume end-systolic volume
The amount of blood in the ventricle at the end of the cardiac ejection period and immediately preceding ventricular relaxation; used as a measure of systolic function. was higher (84.1 [+ or -] 24.9 ml vs 74.6 [+ or -] 22.0 ml, p=0.012) in patients with RBBB. Number of patients with high Killip grade (III and IV) was more in the RBBB group [7 (18.9%) vs 3 (7.5%), RR: 1.75, %95 CI 0.92-3.32, p=0.14], and number of patients with Killip grade I was more in the control group [34 (85.0%) vs 22 (59.5%), p=0.012]. Besides mean Killip class was higher in the RBBB group (1.65 [+ or -] 0.90 vs 1.25 [+ or -] 0.67, p=0.03). Three patients (8.1%) in the RBBB group and 2 patients (5.0%) in the control group died during hospitalization (p=0.67).
Conclusion: Left ventricular ejection fraction decreases and Killip grade increases in case of RBBB in the setting of acute anterior MI. Culprit lesion in patients with RBBB is more commonly a LAD proximal lesion and threatened myocardial myocardial /myo·car·di·al/ (-kahr´de-al) pertaining to the muscular tissue of the heart.
pertaining to the muscular tissue of the heart (the myocardium). tissue is larger in patients with RBBB.
Key words: Acute anterior myocardial infarction, coronary angiography coronary angiography Interventional cardiology A diagnostic technique in which a radiocontrast is injected directly into the coronary arteries, allowing visualization and quantification of stenosis and/or obstruction. , right bundle branch block
Amac: Akut anterior miyokard infarktusu (MI) ile sag dal blogu (RBBB) birlikteliginde hastalarm fonksiyonel durumunu (Killip synyflamasy), sol ventrikul kontraktilitesini, anjiyografik anatomiyi ve koroner lezyon ciddiyetini degerlendirmek.
Yontemler: Akut anterior MI tanisi ile 1999-2005 yillari arasinda koroner yogun bakim unitesine yatirilan 792 hasta retrospektif olarak tarandi. Bu hastalarin 37'sinde basvuru elektrokardiyogramlarinda (EKG EKG: see electrocardiography. ) ya da takiplerinde RBBB izlenmisti (RBBB grubu). Akut anterior MI seyrinde intraventrikuler ileti defekti bulunmayan benzer demografik ozelliklere sahip 40 hasta ise kontrol grubu olarak calismaya alindi. Bu hastalarin koroner anjiyografi ile ekokardiyografi bulgulari, Killip siniflamasi ve hastane ici mortaliteleri arastirildi.
Bulgular: Otuz yedi hastanyn 30'unun basvuru EKG'sinde RBBB mevcuttu. Geri kalan 7'sinde ise takipte RBBB gelismisti. Sag dal blogu grubunda infarktusten sorumlu lezyon sol on inen (LAD) arterde daha proksimalde bir lezyondu (23 [%62.2]'e karsin 11 [%27.5], P=0.003). Sol ventrikul ejeksiyon fraksiyonu RBBB grubunda daha dusukken (%33.0 [+ or -] 4.2'e karsin %36.7 [+ or -] 4.9, p=0.003) sol ventrikul sistol sonu capi daha yuksekti (84.1 [+ or -] 24.9 ml karsin 74.6 [+ or -] 22.0 ml, p=0.012). Istatistiksel olarak anlamli olmasa da yuksek Killip sinifi olan hastalar (Killip sinif III ve IV) RBBB grubunda daha fazla sayidaydi (7'ye karsin 3, RR: 1.75, %95 CI 0.92-3.32, p=0.14) aksine Killip sinifi I olan hasta sayisi kontrol grubunda anlamli oranda daha fazlaydi (22'ye karsin 34, RR: 0.80, %95 CI 0.62-1.03, P = 0.029). Ayrica RBBB grubunda ortalama Killip sinifi daha yuksekti (1.65 [+ or -] 0.90'a karsin 1.25 [+ or -] 0.67, P=0.03). Sag dal blogu grubundaki 3 (%8.1) hasta ve kontrol grubundaki 2 (%5.0) hasta hastanedeki takibi esnasynda eksitus oldu (p=0.67).
Sonuc: Akut anterior MI ve RBBB birliktelioinde ejeksiyon fraksiyonu dusmektedir ve Killip sinifi artmaktadyr. Bu hastalarda infarktus ile iliskili lezyon siklikla LAD proksimal lezyonudur, dolayisiyla daha genis bir miyokard alam tehdit altyndadyr.
Anahtar kelimeler: Akut anterior miyokard infarktusu, koroner anjiyografi, sag dal blok
The prevalence of bundle branch block Bundle Branch Block Definition
Bundle branch block (BBB) is a disruption in the normal flow of electrical pulses that drive the heart beat.
Description in the setting of acute myocardial infarction acute myocardial infarction (·kyōōtˑ mī·ō·karˑ·dē· (MI) is 1.6-10.9% in different series (1-3) and no significant difference is found between left bundle branch block left bundle branch block Cardiology A condition in which ventricular contraction is not completely synchronized due to a block in conduction of an electrical impulse to the ventricles; in LBBB, right ventricular endocardial activation begins before, and is often or right bundle branch block (RBBB). Development of a new bundle branch block either left or right in the setting of acute MI indicates presence of an extensive MI (4) and poor prognosis (5). In a recent study (6), even in the coronary intervention era, RBBB has been found to be still associated with an increased 30-day mortality rate.
However, the importance of RBBB in acute anterior MI is still underrecognized and RBBB is not present in current risk stratification risk stratification Medical decision-making The constellation of activities–eg, lab and clinical testing used to determine a person's risk for suffering a particular condition and need–or lack thereof–for preventive intervention algorithms ("Thrombolysis In Myocardial Infarction Thrombolysis In Myocardial Infarction (TIMI) is a large randomized controlled trial into myocardial infarction (heart attacks) and the use of thrombolysis. External links
The two main arteries that provide blood to the heart. The coronary arteries surround the heart like a crown, coming out of the aorta, arching down over the top of the heart, and dividing into two branches. ") (7, 8) and is not accepted as a major risk factor in the current guidelines (9, 10). However occurrence of RBBB may be seen with more proximal left anterior descending artery (LAD) involvement, as a result its prognosis may be worse due to a larger myocardial area which is jeopardized and early revascularization with primary percutaneous coronary intervention Percutaneous coronary intervention (PCI), commonly known as coronary angioplasty or simply angioplasty, is a therapeutic procedure to treat the stenotic (narrowed) coronary arteries of the heart found in coronary heart disease. (PCI (1) (Payment Card Industry) See PCI DSS.
(2) (Peripheral Component Interconnect) The most widely used I/O bus (peripheral bus). ) can be more beneficial in patients with RBBB.
We designed this study to investigate the functional status of patients (Killip class), left ventricular contractility, angiographic anatomy and severity of coronary lesions in patients with and without RBBB in the setting of anterior MI.
Patients admitted to our coronary care unit with the diagnosis of acute anterior MI between 1999 and 2005 were retrospectively searched from our database. Out of 792 patients, 37 had RBBB either at admission or in the course of acute MI and underwent coronary angiography (RBBB group). Forty patients who developed no intraventricular conduction defect during the course of acute MI with the same demographic characteristics were selected as the control group.
Electrocardiography electrocardiography (ĭlĕk'trōkärdēŏg`rəfē), science of recording and interpreting the electrical activity that precedes and is a measure of the action of heart muscles.
The electrocardiograms of the patients were reviewed by experienced cardiologists. Acute anterior MI was diagnosed if there was [greater than or equal to] 2 mm of ST elevation in two contiguous leads between V1 and V3. Isolated ST elevation of [greater than or equal to] 1 mm in two contiguous lateral leads between V4 and V6, I, and AVL (Automatic Vehicle Location) See mobile positioning. was also classified as acute anterior MI (9, 11). The RBBB was defined as a prolonged (IRS An abbreviation for the Internal Revenue Service, a federal agency charged with the responsibility of administering and enforcing internal revenue laws. duration of [greater than or equal to] 0.12 seconds or an rsr', rsR', or rSR' patterns in lead V1 or V2. Leads V6 and I had to show a (IRS complex with a wide S-wave (S duration [greater than or equal to] R duration or [greater than or equal to] 0.04 s (12). An intraventricular conduction defect was defined as any situation in which (IRS duration is [greater than or equal to] 0.12 seconds.
Echocardiography Echocardiography Definition
Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart muscle. Ultrasound waves that rebound or echo off the heart can show the size, shape, and movement of the heart's valves and
All patients underwent complete transthoracic transthoracic /trans·tho·rac·ic/ (-thah-ras´ik) through the thoracic cavity or across the chest wall.
Across or through the thoracic cavity or chest wall. echocardiographic studies in 72 hours after MI, which include two dimensional, color flow and pulsed Doppler imaging with a GE-Vingmed Vivid 3 system (GE-Vingmed Ultrasound AS, Horten, Norway). Standard transthoracic echocardiographic views were used to obtain left ventricular (LV) ejection fraction (EF), LV end-diastolic diameter, LV end-diastolic and end-systolic volumes. Left ventricular EF (%) was calculated according to the following formula: "100 x [(left ventricular end-diastolic volume--left ventricular end-systolic volume) / left ventricular end-diastolic volume end-diastolic volume
The amount of blood in the ventricle immediately before a cardiac contraction begins; used as a measurement of diastolic function. ]" (13).
Standard selective coronary angiography with at least 4 views of the left coronary system and 2 views of the right coronary artery coronary artery
1. An artery with origin in the right aortic sinus; with distribution to the right side of the heart in the coronary sulcus, and with branches to the right atrium and ventricle, including the atrioventricular branches and was performed using the Judkins technique. In 2 (4.9%) patients in the RBBB group and 2 (5.0%) patients in the control group who underwent primary PCI for acute MI, only left coronary system views were available. Culprit lesion was defined as proximal left anterior descending artery (LAD) lesion if it was between LAD ostium ostium /os·ti·um/ (os´te-um) pl. os´tia [L.] an opening or orifice.os´tial
ostium abdomina´le tu´bae uteri´nae and first septal septal /sep·tal/ (sep´tal) pertaining to a septum.
Of or relating to a septum or septa. or diagonal artery, distal LAD lesion if it was distal to the first septal or diagonal artery. Significant coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. (CAD) was defined as lesions [greater than or equal to] 70% by visual examination of any main epicardial epicardial
pertaining to the visceral pericardium (epicardium) or to the epicardia.
receptors in the left ventricle adapted to respond to stretch and chemical stimulants. coronary artery and [greater than or equal to] 50% in the left trunk. For the analysis of multivessel disease multivessel disease Cardiology CAD involving 2 or more coronary arteries. See Coronary artery disease. in acute anterior MI, the number of diseased vessels was identified according to the number of the major coronary arteries having [greater than or equal to] 70% stenosis.
Coronary angiography and echocardiographic findings, Killip classification and in-hospital mortality of the patients with RBBB and the control group were investigated.
The statistical analysis of the results was performed using the Statistical Package for Social Sciences (SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. , Chicago, Illinois, USA), version 11.5 software for Windows. Data were tested for normal distribution using the Kolmogorov-Smirnov test. The nominal variables were shown as number of cases with percentage and continuous variables were shown as mean [+ or -] standard deviation In statistics, the average amount a number varies from the average number in a series of numbers.
(statistics) standard deviation - (SD) A measure of the range of values in a set of numbers. . The Chi-square test chi-square test: see statistics. or Fisher's exact test Fisher's exact test
a statistical test for association in a two-by-two table based on the exact hypergeometric distribution of the frequencies within the table. was used for the categorical comparisons. Whether the mean differences between RBBB group and control group were significant or not were evaluated using Student's t test or non-parametric Mann-Whitney U test Mann-Whitney U test,
n.pr See test, Mann-Whitney U. . P value of <0.05 was considered as significant.
The demographic characteristics of the patients were similar (Table 1). Out of 37 patients in the RBBB group, 30 had RBBB at admission and the rest 7 developed RBBB in the course of acute MI. None of the recently developed RBBB and 4 of the 30 RBBB at admission, a total number of 4 (10.8%) from 37 RBBB resolved before hospital discharge. Out of these patients, 16 (43.2%) of them underwent primary PCI, and thrombolytic thrombolytic /throm·bo·lyt·ic/ (throm?bo-lit´ik) dissolving or splitting up a thrombus, or an agent that so acts.
1. dissolving or splitting up a thrombus.
2. an agent that dissolves or splits up a thrombus. treatment was administered to 21 (56.8%) patients. In control group, 15 (37.5%) underwent primary PCI and thrombolytic treatment was administered to 25 (62.5%) patients. No significant difference was found between two groups when the treatment strategies for acute MI were considered (p=0.5).
All patients in both groups underwent coronary angiography before hospital discharge. The clinical, echocardiographic and angiographic characteristics of the patients are highlighted in Table 2. The LAD proximal lesion was detected more commonly in patients with RBBB. Besides LVEF LVEF Left ventricular ejection fraction. See Ejection fraction. was lower (p=0.003) and LV end-systolic volume was higher (p=0.01) in patients with RBBB (Table 2). Number of patients with high Killip grade (111 and IV) was more in the RBBB group [7(18.9%) vs 3 (7.5%), RR: 1.75, %95 CI 0.92-3.32, P=0.141, and number of patients with Killip grade I was more in the control group [34 (85.0%) vs 22(59.5%), p=0.0121. Besides mean Killip score was higher (p=0.03) in the RBBB group as compared with control one (Table 2). Three patients (8.1%) in the RBBB and 2 patients (5.0%) in the control group died during hospitalization (p=0.667).
In this study, we showed that RBBB in the course of acute anterior MI has worse clinical and angiographic characteristics when compared to patients with no intraventricular defect. This is an important finding because early revascularization of patients with RBBB may be more important to salvage more myocardial tissue.
Wong et al (11) demonstrated that RBBB in the setting of acute anterior MI was an independent 30-day mortality predictor. In this study, the baseline clinical characteristics were worse in RBBB group but after adjustment for these factors, 30-day mortality was still higher in patients with anterior MI and RBBB. In our study, the clinical characteristics of two groups were similar and we could not show a mortality difference but our study population was small and only in-hospital short-term mortality was investigated. Because the patients with RBBB had more proximal LAD involvement, the jeopardized myocardial area was larger and as a result they might have higher long-term mortality and morbidity rates.
In a recently published article (14), RBBB was found to be only related to increased risk of sudden cardiac death/resuscitated cardiac arrest cardiac arrest
Abbr. CA A sudden cessation of cardiac function, resulting in loss of effective circulation.
A condition in which the heart stops functioning. but left bundle branch block was associated with increased risk for all-cause death, cardiovascular death, and sudden cardiac death/resuscitated cardiac arrest. But in this study, patients with non-anterior MI had been also included. The prognosis of co-existence of RBBB with inferior MI was not different from the ones with normal conduction in another study (11). This may explain those findings in the study by Bogale et al (14).
In the article by Di Chiara (15), it was stated that RBBB should be 'blindly' considered as a consequence of acute anterior MI. In our study, LAD proximal lesions were found to be more common in patients with RBBB. This finding is consistent with this theory because proximal LAD occlusion before septal artery may lead to RBBB due to septal ischemia.
Killip class was higher and heart failure was more common in patients with RBBB as a result of more proximal LAD occlusion and more jeopardized myocardial tissue. Besides in patients with RBBB, LV EF was lower and LV end-systolic diameter was higher. There was no difference between two groups with respect to LV end-diastolic diameter. This may be explained by the early timing of echocardiography because there has been no time for LV remodeling remodeling /re·mod·el·ing/ (re-mod´el-ing) reorganization or renovation of an old structure.
bone remodeling in these patients. These are important findings because prompt treatment with early percutaneous revascularization may decrease this potentially fatal complication, heart failure due to ischemic cardiomyopathy ischemic cardiomyopathy Cardiology A disorder caused by myocardial hypoxia, which compromises the heart's ability to efficiently pump blood; IC may cause heart failure and is a complication of cardiac ischemia, especially affecting older ♂, a disparity that , and improve their prognosis.
However, even coronary intervention was performed at approximately a mean of 4 hours after chest pain, RBBB was found to be still associated with a higher mortality in patients with acute anterior MI (6). Nevertheless, earlier recognition and emergent percutaneous intervention percutaneous intervention Cardiology An intravascular procedure performed without a large operative field Types Diagnostic catheterization, cardiac revascularization, angioplasty, stent placement of these patients may be beneficial to salvage more myocardial tissue.
The resolution of bundle branch block has been reported in several studies (16-18) after PCI or thrombolytic treatment. A resolution rate of 12% was reported by Sgarbossa et al (1). Our results were also comparable with this study (10.8% resolution of RBBB).
Limitations of the study
Our study has several limitations. It is a retrospective study retrospective study,
a study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g. which does not have enough power to show increased mortality in patients with RBBB as shown before (5). Despite careful selection of the control group to match with the RBBB group with regard to the baseline demographic characteristics (primary PCI or thrombolytic treatment), there may be a selection bias in the control group.
The culprit lesion inpatients with RBBB and acute anterior MI is more commonly a LAD proximal lesion and jeopardized myocardial tissue is larger in patients with RBBB. As a result, these patients should receive more aggressive treatment with early revascularization to decrease morbidity and mortality Morbidity and Mortality can refer to:
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See urokinase. ] for Occluded Coronary Arteries. J Am Coll Cardiol 1998; 31: 105-10.
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TIMI Technology Independent Machine Interface (IBM AS/400)
TIMI Technical Information Maintenance Instruction risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation: an Intravenous nPA for Treatment of Infarcting Myocardium myocardium /myo·car·di·um/ (-kahr´de-um) the middle and thickest layer of the heart wall, composed of cardiac muscle.
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in full Uniform Resource Locator
Address of a resource on the Internet. The resource can be any type of file stored on a server, such as a Web page, a text file, a graphics file, or an application program. : www.acc.org/clinical/guidelines/stemi/index.pdf
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Ugur Arslan, Serhat Balcioglu, Yusuf Tavil, Murat Ozdemir, Atiye Cengel
Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
Address for Correspondence/Yazisma Adresi: Dr. Ugur Arslan, Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey Phone: +90 312 202 56 29 Fax: +90 312 202 90 12 E-mail: ugurarslan5Qyahoo.com
Table 1. Demographic characteristics of the patients Variable RBBB group Control group (n=37) (n=40) p Age, years 57.6 [+ or -] 11.5 57.8 [+ or -] 11.3 NS Male sex, n (%) 32 (86.5) 35 (87.5) NS Risk factors, n (%) Diabetes Mellitus 5 (13.5) 6 (15.0) NS Hypertension 14 (37.8) 16 (40.0) NS Hyperlipidemia 9 (18.9) 8 (20.0) NS Family history for CAD 11 (29.7) 11 (27.5) NS Cigarette smoking, n (%) Current smoker 13 (35.1) 14 (35.0) Past smoking 9 (24.3) 11 (27.5) NS Never used 15 (40.5) 15 (37.5) Data are represented as Mean [+ or -] SD and percentages/ proportions Student's t and Chi-square tests were used. CAD - coronary artery disease, NS - not significant, RBBB - right bundle branch block Diabetes mellitus was defined in patients who were already using anti-diabetic medication. Hypertension was defined as blood pressure >140/90 mmHg after the initial stressful event with chest pain resolved or current usage of antihypertensive drugs. Hyperlipidemia was defined in patients whose fasting plasma low density lipoprotein levels>130 mg/dl or triglyceride levels >200 mg/dl. Family history was defined as early occurrence of CAD in first degree family members. Table 2. Clinical, echocardiographic and angiographic characteristics of the patients RBBB group Variable (n=37) Localization of culprit lesion, (%) Proximal LAD artery 23 (62.2) Distal LAD artery 14 (37.8) Killip classification, n (%) Class I 22 (59.5) Class II 8 (21.6) Class III 4 (10.8) Class IV 3 (8.1) Mean Killip score 1.65 [+ or -] 0.90 Death, n (%) 3 (8.1) Other vessel involvement, n(%) Left main coronary artery 1 (2.7) Circumflex artery 13 (35.1) Right coronary artery 11 (29.7) Classification according to vessel involvement, n(%) 1-vessel disease 16 (43.3) 2-vessel disease 18 (48.6) 3-vessel disease 3 (8.1) Echocardiographic findings LV end-diastolic diameter, mm * 50.1 [+ or -] 6.1 (49, 37-60) LV end-diastolic volume, ml 121.1 [+ or -] 30.0 LV end-systolic volume, ml 84.1 [+ or -] 24.9 LV ejection fraction, % 33.0 [+ or -] 4.2 Control group Variable (n=40) p Localization of culprit lesion, (%) Proximal LAD artery 11 (27.5) 0.003 Distal LAD artery 29 (72.5) Killip classification, n (%) Class I 34 (85.0) Class II 3 (7.5) 0.108 Class III 2 (5.0) Class IV 1 (2.5) Mean Killip score 1.25 [+ or -] 0.67 0.03 Death, n (%) 2 (5.0) NS Other vessel involvement, n(%) Left main coronary artery 1 (2.5) NS Circumflex artery 14 (35.0) NS Right coronary artery 10 (25) NS Classification according to vessel involvement, n(%) 1-vessel disease 18 (45.0) 2-vessel disease 20 (50.0) NS 3-vessel disease 2 (5.0) Echocardiographic findings LV end-diastolic diameter, mm * 49.5 [+ or -] 6.4 NS (50, 37-62) LV end-diastolic volume, ml 120.2 [+ or -] 29.8 NS LV end-systolic volume, ml 74.6 [+ or -] 22.0 0.012 LV ejection fraction, % 36.7 [+ or -] 4.9 0.003 Data are represented as Mean [+ or -] SD, percentages/ proportions and * median, minimum-maximum values; Mann-Whitney U test, unpaired Student's t test, Chi-square and Fisher's exact tests LAD-left anterior descending artery, LT left ventricle, NS-not significant, RBBB-right bundle branch block