Management of Patients With LBB and Suspected MI

Conclusions

Patients with a suspected ACS in the setting of LBBB represent a much more heterogeneous population than STEMI without BBB and present unique diagnostic and therapeutic challenges to the clinician. Most patients will not have an AMI regardless of LBBB chronicity and likely would not benefit from urgent reperfusion therapy. Current guideline recommendations and performance measures do not account for the evolving epidemiology and complexity of LBBB among patients with possible ACS. We recommend a slightly more judicious approach to diagnosis among hemodynamically and clinically stable patients with LBBB who do not have ECG findings highly specific for STEMI. Moreover, we recommend a higher threshold for pharmacological reperfusion than primary PCI, given the lower probability of an occluded culprit artery and the bleeding risks of fibrinolytic therapy. The full impact of this approach, with regard to appropriateness and timeliness of therapy, as well as outcomes, requires prospective study.