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RIGTH BUNDLE BRANCH BLOCK AS RISK
MARKER OF IN HOSPITAL MORTALITY IN STELEVATION ACUTE MYOCARDIAL
INFARCTION. A RENASICA - II SUBSTUDY
National Registry of Mexican Society of
Cardiology
Authors : Úrsulo Juárez MD FACC , Carlos Jerjes-Sanchez
MD FACC, Eduardo Chuquiure MD , Carlos Martínez MD
FACC
On Behalf of RENASICA II and Sociedad Mexicana de
Cardiología, México City, México.
ESC Congress 2007
BACKGROUND-1
• Bundle branch block (BBB) early during acute myocardial
infarction (AMI) is often considered high risk for mortality
• In the Fibrinolytic Therapy Trialists’ meta-analysis, patients
with BBB at randomization had a 35-day mortality rate of 24%
without and 19% with fibrinolytic therapy. The studies
included made no distinction between rigth bundle branch
block (RBBB) and left bundle branch block (LBBB) and did
not specify whether the BBB was new or old
• Different types of BBB occurring during the initial hours of
AMI may have different prognostic implications that are
independient of another prognostic factors
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BACKGROUND-2
• Development of new BBB despite prompt fibrinolytic
therapy may signify an extensive and ongoing AMI. Some
types of BBB may reflect larger infarct territories, indicating
that these patients might benefit from more aggressive
reperfusion therapy
• Until our knowledgment the prognosis of RBBB in patients
with acute coronary syndromes is unclear
Reference : European Heart Journal (2006)27,21-28
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METHODS-1
The RENASICA II Design overview
• Is the largest national registry of ACS recruited 8,098 patients
with final diagnosis of ACS ST elevation (STE) or non-ST
elevation (NSTE) secundary to ischaemic heart disease and
designed to characterize an unbiased and representative
population
• The patients were enrrolled in 66 primary and tertiary
Mexican Hospitals and for quality control criteria af Alpert were
used. The hospitals varied in terms of access to on-site cardiac
catheterization, number of acute care beds and the type of
practice setting with an aim of stlablishing a representative
rather than selective study population
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METHODS – 2 :
• Patients with ST acute myocardial infarction (AMI) with LBBB
or RBBB were compared in terms of in-hospital outcome and
major cardiovascular adverse events (MACE) , cardiovascular
death, myocardial infarction (MI) and recurrent ischaemia
• patients with symptoms precipitated by anemia,hypertension,
heart failure, etc were excluded
• BBB was defined as de the QRS duration of 0.12 sec in
precence sinus or supraventricular rhythm
• Multivariable Analysis was performed to identify in hospital
mortality risk among RBBB and LBBB with MACE
• Odd ratio (OR) and confidence intervals 95% (CI)
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RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN HOSPITAL
MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL INFARCTION. A
RENASICA- II SUBSTUDY
Inclusion Criteria
INCLUSION (4)
1. lchemic Chest Pain > 20 min
2. ST-E: in BL > 1 mm; Precordial leads > 2 mm
3. QRS duration > 0.12 seg.
4. Complete Register Form – Signed IC
EXCLUTION (1)
1. Non Ischaemic CP precipitated by secundary cause
as anemia, heart failure or hypertension
2. Previous BBB
3. Pacemaker rythm
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QUALITY
To ensure quality control of registry data the following criteria
developed by Alpert were applied in RENASICA II:
a) Standarizad definitions and all participants were familiarizad
b) Careful hospitals selection
c) Hospitals approved registry data collection process
d) All collected data were reported
e) Original data,electronic submissions were centralized
f) A professional statistician analyzed the data
g) All data and electronic submissions were examined by the
central data management
h) Principal investigator and steering committee keep
administrative order, adjudicated disagreements and
encouraged timely submission of documents and data
analysis.
ESC Congress 2007
RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN
HOSPITAL MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL
INFARCTION. A RENASICA- II SUBSTUDY
RESULTS
• 4,555 patients with STE AMI were analyzed in this substudy
• Of them 7% had RBBB and 5% LBBB
• There were not statistical differences in both groups among
aged, gender baseline characteristics, onset symptoms,
ischemic time, AMI location, Killip functional class, ventricular
dysfunction, and reperfusion strategies.
• Patients with inferior or anterior STE AMI with RBBB had
highest mortality and association with MACE ( OR 1.70, CI
1.19 – 2.42, p< 0.003 compared to LBBB.
ESC Congress 2007
RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN
HOSPITAL MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL
INFARCTION. A RENASICA- II SUBSTUDY
n = 8,098 Patients with
ACS
Unspeciphic Chest Pain
n = 625 (7%)
UA / Non ST AMI*
n = 3,445 (40%)
RBBB n= 318 (7%)
* UA/Non ST AMI = Unstable Angina No ST elevation acute
myocardial infarction
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STE AMI**
n = 4,555 (53%)
LBBB n= 227 (5%)
** STE AMI = ST elevation acute myocardial infarction
RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN
HOSPITAL MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL
INFARCTION. A RENASICA- II SUBSTUDY
ACS-AMI-ST ELEVATION
RENASICA – II REGISTRY
n = 4,555 STEMI
BBB n = 545 patients
RIGTH BUNDLE BRANCH
BLOCK
N = 318 ( 7% )
LEFT BUNDLE BRANCH
BLOCK
N = 227 ( 5% )
In Hospital Outcome – Major Cardiovascular Adverse Events – Cardiovascular Death
Recurrent ischemia – Re AMI
Multivariable Analysis to In Hospital Mortality Risk among RBBB and LBBB with MACE
Odd Ratio (OR) and Confidence Intervals 95%
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Baseline Characteristics-1
Characteristic
RBBB
LBBB
(n=318)
(n=227)
Age-years-median
66.7
Men (%)
76
Hypertension (%)
55
Hyperlipidemia (%)
27
Current/former smoker (%) 63
Diabetes (%)
48
Previous AMI (%)
23
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67.3
71
59
26
66
47
35
all p = NS
Baseline Characteristics-2
Characteristic
AMI location (%)
Anterior
Inferior
K Killip I
II
III
IV
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(n =)
RBBB
LBBB
(n=318)
(n=227)
32
23
23
16
235
54
16
13
168
38
12
9
All p = NS
TREATMENT
Medication
Reperfusion Strategy
Lytic (%)
Primary PTCA (%)
Clopidogrel (%)
ASA (%)
Beta Bloq.(%)
IECA/ARB (%)
Statins (%)
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RBBB
(n=318)
LBBB
(n=227)
32
23
23
20
44
88
51
64
14
38
89
51
59
13
all p = NS
Outcomes in Hospital
Comparison in both BBB and MACE
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30
30
29
%
28
27
26
25
24
23
22
21
20
20
19
18
17
16
15
14
13
12
10
11
10
9
8
7
6
5
4
03
2
1
0
RBBB
LBBB
20
19
10
6
Death
*
Re-Angina
P value = ns
6
7
Re-AMI
IN HOSPITAL MORTALITY PREDICTORS IN STEMI
A SUBSTUDY OF RENASICA II
findings ECG
(OR 1.7, CI 1.1 – 2.5)
LBBB
(OR 1.7, CI 1.1 – 2.4)
RBBB
(OR 2.4, 95% CI 1.9 –3.1)
3rd degree AV block
ST Depresion in > 3
ECG leads
0.5
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1.0
2.0
5.0
10
100
logistic regresion in mortality predictors
Clinical Implications
• The higher mortality and higher incidence of RBBB seen in
patients with anterior AMI may be axplained by:
• Septal ischaemia from a more proximal left descending artery
occlusion (before the large septal branch)
• The course of the rigth bundle branch traversing the septum
towards the apex.
Limitations
• As in all clinical trials, a selection bias could have occurred in
RENASICA II resulting in under-representation of very high risk
patients (including those with RBBB accompanying anterior
AMI) in the trial cohort.
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RIGTH BUNDLE BRANCH BLOCK AS RISK MARKER OF IN
HOSPITAL MORTALITY IN ST-ELEVATION ACUTE MYOCARDIAL
INFARCTION. A RENASICA- II SUBSTUDY
Conclusion
The RBBB accompanying anterior or inferior AMI at
presentation was an independient predictor of high in
hospital mortality. These electrocardiographics features
should be considered in risk stratification to identify highrisk patients
ESC Congress 2007