esc congress 2007 rigth bundle branch block as risk marker of in hospital mortality in st- elevation...

ESC Congress 2007ESC Congress 2007

RIGTH BUNDLE BRANCH BLOCK AS RISK RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN HOSPITAL MORTALITY IN ST-MARKER OF IN HOSPITAL MORTALITY IN ST-

ELEVATION ACUTE MYOCARDIAL ELEVATION ACUTE MYOCARDIAL INFARCTION. A RENASICA - II SUBSTUDYINFARCTION. A RENASICA - II SUBSTUDY

National Registry of Mexican Society of National Registry of Mexican Society of CardiologyCardiology

Authors : Úrsulo Juárez MD FACC , Carlos Jerjes-Sanchez Authors : Úrsulo Juárez MD FACC , Carlos Jerjes-Sanchez MD FACC, Eduardo Chuquiure MD , Carlos Martínez MD MD FACC, Eduardo Chuquiure MD , Carlos Martínez MD FACCFACC

On Behalf of RENASICA II and Sociedad Mexicana de On Behalf of RENASICA II and Sociedad Mexicana de Cardiología, México City, México. Cardiología, México City, México.

BACKGROUND-1BACKGROUND-1

• Bundle branch block (BBB) early during acute myocardial Bundle branch block (BBB) early during acute myocardial infarction (AMI) is often considered high risk for mortalityinfarction (AMI) is often considered high risk for mortality

• In the Fibrinolytic Therapy Trialists’ meta-analysis, patients In the Fibrinolytic Therapy Trialists’ meta-analysis, patients with BBB at randomization had a 35-day mortality rate of 24% with BBB at randomization had a 35-day mortality rate of 24% without and 19% with fibrinolytic therapy. The studies without and 19% with fibrinolytic therapy. The studies included made no distinction between rigth bundle branch included made no distinction between rigth bundle branch block (RBBB) and left bundle branch block (LBBB) and did block (RBBB) and left bundle branch block (LBBB) and did not specify whether the BBB was new or oldnot specify whether the BBB was new or old

• Different types of BBB occurring during the initial hours of Different types of BBB occurring during the initial hours of AMI may have different prognostic implications that are AMI may have different prognostic implications that are independient of another prognostic factorsindependient of another prognostic factors


BACKGROUND-2BACKGROUND-2

• Development of new BBB despite prompt fibrinolytic Development of new BBB despite prompt fibrinolytic therapy may signify an extensive and ongoing AMI. Some therapy may signify an extensive and ongoing AMI. Some types of BBB may reflect larger infarct territories, indicating types of BBB may reflect larger infarct territories, indicating that these patients might benefit from more aggressive that these patients might benefit from more aggressive reperfusion therapyreperfusion therapy

• Until our knowledgment the prognosis of RBBB in patients Until our knowledgment the prognosis of RBBB in patients with acute coronary syndromes is unclearwith acute coronary syndromes is unclear

Reference : European Heart Journal (2006)27,21-28Reference : European Heart Journal (2006)27,21-28


METHODS-1METHODS-1

The RENASICA II Design overviewThe RENASICA II Design overview

• Is the largest national registry of ACS recruited 8,098 patients Is the largest national registry of ACS recruited 8,098 patients with final diagnosis of ACS ST elevation (STE) or non-ST with final diagnosis of ACS ST elevation (STE) or non-ST elevation (NSTE) secundary to ischaemic heart disease and elevation (NSTE) secundary to ischaemic heart disease and designed to characterize an unbiased and representative designed to characterize an unbiased and representative populationpopulation

• The patients were enrrolled in 66 primary and tertiary The patients were enrrolled in 66 primary and tertiary Mexican Hospitals and for quality control criteria af Alpert were Mexican Hospitals and for quality control criteria af Alpert were used. The hospitals varied in terms of access to on-site cardiac used. The hospitals varied in terms of access to on-site cardiac catheterization, number of acute care beds and the type of catheterization, number of acute care beds and the type of practice setting with an aim of stlablishing a representative practice setting with an aim of stlablishing a representative rather than selective study populationrather than selective study population


METHODS – 2 :METHODS – 2 :

• Patients with ST acute myocardial infarction (AMI) with LBBB Patients with ST acute myocardial infarction (AMI) with LBBB or RBBB were compared in terms of in-hospital outcome and or RBBB were compared in terms of in-hospital outcome and major cardiovascular adverse events (MACE) , cardiovascular major cardiovascular adverse events (MACE) , cardiovascular death, myocardial infarction (MI) and recurrent ischaemiadeath, myocardial infarction (MI) and recurrent ischaemia

• patients with symptoms precipitated by anemia,hypertension, patients with symptoms precipitated by anemia,hypertension, heart failure, etc were excludedheart failure, etc were excluded

• BBB was defined as de the QRS duration of 0.12 sec in BBB was defined as de the QRS duration of 0.12 sec in precence sinus or supraventricular rhythmprecence sinus or supraventricular rhythm

• Multivariable Analysis was performed to identify in hospital Multivariable Analysis was performed to identify in hospital mortality risk among RBBB and LBBB with MACEmortality risk among RBBB and LBBB with MACE

• Odd ratio (OR) and confidence intervals 95% (CI)Odd ratio (OR) and confidence intervals 95% (CI)


Inclusion CriteriaInclusion CriteriaINCLUSION (4)INCLUSION (4)

1. lchemic Chest Pain 1. lchemic Chest Pain >> 20 min 20 min2. ST-E: in BL 2. ST-E: in BL >> 1 mm; Precordial leads 1 mm; Precordial leads >> 2 mm 2 mm 3. QRS duration > 0.12 seg.3. QRS duration > 0.12 seg.

4. Complete Register Form – Signed IC4. Complete Register Form – Signed IC

EXCLUTION (1)EXCLUTION (1)1. Non Ischaemic CP precipitated by secundary cause 1. Non Ischaemic CP precipitated by secundary cause

as anemia, heart failure or hypertension as anemia, heart failure or hypertension

2. Previous BBB2. Previous BBB 3. Pacemaker rythm 3. Pacemaker rythm

RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN HOSPITAL RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN HOSPITAL MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL INFARCTION. A MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL INFARCTION. A

RENASICA- II SUBSTUDYRENASICA- II SUBSTUDY


To ensure quality control of registry data the following criteria To ensure quality control of registry data the following criteria developed by Alpert were applied in RENASICA II:developed by Alpert were applied in RENASICA II:

a)a) Standarizad definitions and all participants were familiarizad Standarizad definitions and all participants were familiarizad

b)b) Careful hospitals selectionCareful hospitals selection

c)c) Hospitals approved registry data collection processHospitals approved registry data collection process

d)d) All collected data were reportedAll collected data were reported

e)e) Original data,electronic submissions were centralizedOriginal data,electronic submissions were centralized

f)f) A professional statistician analyzed the dataA professional statistician analyzed the data

g)g) All data and electronic submissions were examined by the All data and electronic submissions were examined by the central data managementcentral data management

h)h) Principal investigator and steering committee keep Principal investigator and steering committee keep administrative order, adjudicated disagreements and administrative order, adjudicated disagreements and encouraged timely submission of documents and data encouraged timely submission of documents and data analysis.analysis. ESC Congress 2007ESC Congress 2007

QUALITYQUALITY

RESULTSRESULTS

• 4,555 patients with STE AMI were analyzed in this substudy4,555 patients with STE AMI were analyzed in this substudy

• Of them 7% had RBBB and 5% LBBBOf them 7% had RBBB and 5% LBBB

• There were not statistical differences in both groups among There were not statistical differences in both groups among aged, gender baseline characteristics, onset symptoms, aged, gender baseline characteristics, onset symptoms, ischemic time, AMI location, Killip functional class, ventricular ischemic time, AMI location, Killip functional class, ventricular dysfunction, and reperfusion strategies.dysfunction, and reperfusion strategies.

• Patients with inferior or anterior STE AMI with RBBB had Patients with inferior or anterior STE AMI with RBBB had highest mortality and association with MACE ( OR 1.70, CI highest mortality and association with MACE ( OR 1.70, CI 1.19 – 2.42, p< 0.003 compared to LBBB.1.19 – 2.42, p< 0.003 compared to LBBB.


RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN HOSPITAL MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL HOSPITAL MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL

INFARCTION. A RENASICA- II SUBSTUDYINFARCTION. A RENASICA- II SUBSTUDY

RBBB n= 318 (7%)RBBB n= 318 (7%) LBBB n= 227 (5%)LBBB n= 227 (5%)

Unspeciphic Chest Painn = 625 (7%)

Unspeciphic Chest Painn = 625 (7%)

UA / Non ST AMI*n = 3,445 (40%)

UA / Non ST AMI*n = 3,445 (40%)

STE AMI**n = 4,555 (53%)

n = 8,098 Patients with ACS

n = 8,098 Patients with ACS

* UA/Non ST AMI = Unstable Angina No ST elevation acute myocardial infarction

** STE AMI = ST elevation acute myocardial infarction






ACS-AMI-ST ELEVATION ACS-AMI-ST ELEVATION RENASICA – II REGISTRYRENASICA – II REGISTRY n = 4,555 STEMIn = 4,555 STEMI

RIGTH BUNDLE BRANCH RIGTH BUNDLE BRANCH BLOCKBLOCK

N = 318 ( 7% )N = 318 ( 7% )

In Hospital Outcome – Major Cardiovascular Adverse Events – Cardiovascular DeathIn Hospital Outcome – Major Cardiovascular Adverse Events – Cardiovascular DeathRecurrent ischemia – Re AMIRecurrent ischemia – Re AMI

Multivariable Analysis to In Hospital Mortality Risk among RBBB and LBBB with MACEMultivariable Analysis to In Hospital Mortality Risk among RBBB and LBBB with MACEOdd Ratio (OR) and Confidence Intervals 95%Odd Ratio (OR) and Confidence Intervals 95%

LEFT BUNDLE BRANCHLEFT BUNDLE BRANCH

BLOCKBLOCK

N = 227 ( 5% )N = 227 ( 5% )

BBB n = 545 patientsBBB n = 545 patients


Baseline Characteristics-1Baseline Characteristics-1

2323

4848

6363

2727

5555

7676

66.766.7

RBBBRBBB(n=318)(n=318)

3535Previous AMI Previous AMI (%)(%)

5959Hypertension Hypertension (%)(%)

2626Hyperlipidemia Hyperlipidemia (%)(%)

6666Current/former smoker Current/former smoker (%)(%)

4747Diabetes Diabetes (%)(%)

7171Men Men (%)(%)

67.367.3Age-years-Age-years-medianmedian

LBBBLBBB(n=227)(n=227)

CharacteristicCharacteristic

all p = NSall p = NSESC Congress 2007ESC Congress 2007

235235

5454

1616

1313

32322323


168168

3838

1212

99

K Killip I K Killip I (n =)(n =)

II II

IIIIII

IVIV

23231616

AMI location (%)AMI location (%)AnteriorAnteriorInferiorInferior


CharacteristicCharacteristic

All p = NSAll p = NS

Baseline Characteristics-2Baseline Characteristics-2


TREATMENTTREATMENT

646451518888


5959IECA/ARB (%)IECA/ARB (%)

8989ASA (%)ASA (%)5151Beta Bloq.(%)Beta Bloq.(%)


MedicationMedication

1414 1313Statins (%)Statins (%)all p = NSall p = NS

Reperfusion StrategyReperfusion Strategy

Lytic (%)Lytic (%)

Primary PTCA (%)Primary PTCA (%)

3232

2323

2323

2020

Clopidogrel (%) Clopidogrel (%) 44 44 3838


Outcomes in HospitalOutcomes in HospitalComparison in both BBB and MACEComparison in both BBB and MACE

20

6 6

19

107

0123456789

101112131415161718192021222324252627282930

Death Re-Angina Re-AMI

P valueP value = ns = ns

%%

LBBBLBBBRBBBRBBB

*


3030

2020

1010

00

0.5 1.0 2.0 5.0 10 100

LBBB

RBBB

3rd degree AV block

ST Depresion in > 3 ECG leads

(OR 1.7, CI 1.1 – 2.5)

(OR 1.7, CI 1.1 – 2.4)

(OR 2.4, 95% CI 1.9 –3.1)

findings ECG

IN HOSPITAL MORTALITY PREDICTORS IN STEMIIN HOSPITAL MORTALITY PREDICTORS IN STEMI A SUBSTUDY OF RENASICA II A SUBSTUDY OF RENASICA II

logistic regresion in mortality predictorsESC Congress 2007ESC Congress 2007

Clinical ImplicationsClinical Implications

• The higher mortality and higher incidence of RBBB seen in The higher mortality and higher incidence of RBBB seen in patients with anterior AMI may be axplained by:patients with anterior AMI may be axplained by:

• Septal ischaemia from a more proximal left descending artery Septal ischaemia from a more proximal left descending artery occlusion (before the large septal branch)occlusion (before the large septal branch)

• The course of the rigth bundle branch traversing the septum The course of the rigth bundle branch traversing the septum towards the apex.towards the apex.

LimitationsLimitations

• As in all clinical trials, a selection bias could have occurred in As in all clinical trials, a selection bias could have occurred in RENASICA II resulting in under-representation of very high risk RENASICA II resulting in under-representation of very high risk patients (including those with RBBB accompanying anterior patients (including those with RBBB accompanying anterior AMI) in the trial cohort.AMI) in the trial cohort.


ConclusionConclusion

The RBBB accompanying anterior or inferior AMI at The RBBB accompanying anterior or inferior AMI at presentation was an independient predictor of high in presentation was an independient predictor of high in hospital mortality. These electrocardiographics features hospital mortality. These electrocardiographics features should be considered in risk stratification to identify high-should be considered in risk stratification to identify high-risk patientsrisk patients




esc congress 2007 rigth bundle branch block as risk marker of in hospital mortality in st- elevation...

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