Criterios de Barcelona 2020

Journal of the American Heart Association
ORIGINAL RESEARCH
New Electrocardiographic Algorithm for the

Diagnosis of Acute Myocardial Infarction in
Patients With Left Bundle Branch Block
Andrea Di Marco, MD*; Marcos Rodriguez, MD*; Juan Cinca, MD, PhD; Antoni Bayes-Genis, MD, PhD;
Jose T. Ortiz-Perez, MD; Albert Ariza-Solé, MD, PhD; Jose Carlos Sanchez-Salado, MD; Alessandro Sionis, MD, PhD;
Jany Rodriguez, MD; Beatriz Toledano, MD; Pau Codina, MD; Eduard Solé-González, MD; Monica Masotti, MD;
Joan Antoni Gómez-Hospital, MD, PhD; Ángel Cequier, MD, PhD; Ignasi Anguera, MD, PhD
BACKGROUND: Current electrocardiographic algorithms lack sensitivity to diagnose acute myocardial infarction (AMI) in the
presence of left bundle branch block.
METHODS AND RESULTS: A multicenter retrospective cohort study including consecutive patients with suspected AMI and left
bundle branch block, referred for primary percutaneous coronary intervention between 2009 and 2018. Pre-2015 patients
formed the derivation cohort (n=163, 61 with AMI); patients between 2015 and 2018 formed the validation cohort (n=107, 40
with AMI). A control group of patients without suspected AMI was also studied (n=214). Different electrocardiographic criteria
were tested. A total of 484 patients were studied. A new electrocardiographic algorithm (BARCELONA algorithm) was derived
and validated. The algorithm is positive in the presence of ST deviation ≥1 mm (0.1 mV) concordant with QRS polarity, in any
lead, or ST deviation ≥1 mm (0.1 mV) discordant with the QRS, in leads with max (R|S) voltage (the voltage of the largest deflec-
tion of the QRS, ie, R or S wave) ≤6 mm (0.6 mV). In both the derivation and the validation cohort, the BARCELONA algorithm
achieved the highest sensitivity (93%–95%), negative predictive value (96%–97%), efficiency (91%–94%) and area under the
Downloaded from http://ahajournals.org by on July 4, 2020
receiver operating characteristic curve (0.92–0.93), significantly higher than previous electrocardiographic rules (P<0.01); the
specificity was good in both groups (89%–94%) as well as the control group (90%).
CONCLUSIONS: In patients with left bundle branch block referred for primary percutaneous coronary intervention, the
BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI, leading to a diagnostic accuracy compara-
ble to that obtained by ECG in patients without left bundle branch block.
Key Words: acute myocardial infarction ■ electrocardiography ■ left bundle branch block ■ primary percutaneous coronary
intervention
See Editorial by Macfarlane
T
he electrocardiographic diagnosis of acute myo- other hand, patients with LBBB and AMI are usually
cardial infarction (AMI) in patients with left bundle at high risk and often experience delays in reperfusion
branch block (LBBB) is often challenging. On one therapy1 that may lead to critical consequences.2,3
hand, most of patients referred for primary percutane- Unfortunately, even the most recent electrocardio-
ous coronary intervention (pPCI) because of the pres- graphic algorithms4,5 do not afford a diagnostic cer-
ence of LBBB are not experiencing an AMI.1 On the tainty for AMI in patients with LBBB.2,5,6 In the absence
Correspondence to: Andrea Di Marco, MD, Arrhythmia Unit, Heart Disease Institute, Bellvitge University Hospital, Calle feixa llarga s/n, 08907 L’Hospitalet de
Llobregat, Barcelona, Spain. E-mail: ayfanciu@hotmail.com
Supplementary Materials for this article are available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.119.015573
*Dr Di Marco and Dr Rodriguez contributed equally to this work.
For Sources of Funding and Disclosures, see page 14.
© 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative
Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use
is non-commercial and no modifications or adaptations are made.
JAHA is available at: www.ahajournals.org/journal/jaha
J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155731

Di Marco et al Improved Electrocardiographic Diagnosis of AMI With LBBB
Second, we considered as a positive criterion for

CLINICAL PERSPECTIVE AMI the presence of an appreciable (≥1 mm or 0.1 mV)
discordant ST deviation in low-voltage QRS complexes
What Is New? because, in the absence of ischemia, these complexes
• We have identified and validated a new electro- usually show isoelectric ST-segment potentials (Figure 1).
cardiographic algorithm, named the BARCELONA This latter criterion had not yet been explored and re-
algorithm, that significantly improves the per- quired defining the best cutoff value for QRS voltage
formance of previous electrocardiographic cri- below which any discordant ST deviation ≥1 mm (0.1 mV)
teria to diagnose acute myocardial infarction in would be regarded as disproportionate and suggestive of
patients with left bundle branch block. AMI. Of note, leads with low-voltage QRS are a frequent
finding in patients with LBBB and AMI, since AMI is as-
What Are the Clinical Implications? sociated with lower QRS voltages in patients with LBBB.8
• To improve the electrocardiographic diagnosis The objective of this study was to assess whether
of acute myocardial infarction in patients with
the electrocardiographic diagnosis of AMI in the pres-
left bundle branch block will help to reduce
many false activations of the protocols for emer- ence of LBBB improved by considering the presence
gent reperfusion and will help to provide timely of concordant ST depression in any ECG lead and the
reperfusion to those patients who are truly ex- occurrence of discordant and disproportionate ST de-
periencing an acute myocardial infarction. viation in leads with low-voltage QRS complexes.
METHODS
The data that support the findings of this study are
Nonstandard Abbreviations and Acronyms available from the corresponding author upon reason-
able request.
AMI acute myocardial infarction
pPCI primary percutaneous coronary
intervention
Study Design and Patient Selection
This is a retrospective, observational cohort study in-
ROC receiver operating characteristic
volving 4 referral hospitals for pPCI in Barcelona, Spain.
The “Codi IAM” network9 in Catalonia (Spain) provides

early reperfusion, mainly through pPCI, to all patients
of acute ischemia, the LBBB pattern is characterized with suspected ST-segment–elevation myocardial in-
by (1) ST-segment displacement in the opposite direc- farction (STEMI) presenting during the first 12 hours
tion to the polarity of the QRS complex (further referred after the onset of symptoms. According to the Codi
as discordant ST deviation) and (2) the existence of a IAM protocol, the presence of new or presumed new
certain degree of proportionality between the magni- LBBB in association with ischemic symptoms is con-
tude of the discordant ST deviation and the voltage of sidered an indication for pPCI.
the corresponding QRS complex.4,5,7 Thus, in addition In this study, we included all consecutive patients re-
to the clinical symptoms of acute ischemia, the occur- ferred for pPCI because of new or presumed new LBBB
rence of ST elevation concordant with QRS polarity with available ECG recorded at the first medical contact.
(5 points in Sgarbossa rules, referred to as concordant The cohort of patients referred for pPCI between
ST elevation) and the presence of excessive discordant October 2009 and December 2014 formed the deriva-
ST deviation (such as the ST/QRS ratio in the Modified tion sample, while patients referred from January 2015
Sgarbossa Criteria)5 are specific for AMI. However, until June 2018 served as the validation sample.
these criteria have a relatively low sensitivity.2,5,6 In addition, to evaluate the specificity of the proposed
To improve the diagnostic sensitivity of ECG in pa- new electrocardiographic criteria in patients not sus-
tients with LBBB and suspected AMI, we have elabo- pected of having an AMI, we included a control group of
rated 2 new approaches. First, since any ST deviation consecutive patients with complete LBBB who attended
concordant with the QRS should be regarded as ab- the emergency department of Bellvitge University
normal, we hypothesized that not only concordant ST Hospital for any reason other than acute coronary syn-
elevation but also concordant ST depression might be drome or who were referred to this center for electro-
a sign of AMI; we therefore extended the Sgarbossa physiological study or cardiac pacemaker implantation.
rule of concordant ST depression in leads V1 to V3 The clinical data were retrieved from prospective da-
to any other lead. It was hypothesized that this would tabases available at each participating hospital. These
cover the electrocardiographic projection of acute databases register all patients with STEMI treated
ischemia in different myocardial regions. within the Codi IAM protocol since the beginning of this

Figure 1. ECG from a patient without acute myocardial infarction showing isoelectric ST segment or minimal ST deviation
<1 mm (0.1 mV) in leads with low-voltage QRS and the absence of any ST deviation ≥1 mm (0.1 mV) concordant with QRS
polarity.
network in 2009. The study protocol was approved by of Q wave in these leads.4,10 The ST deviation was
the Institutional Ethics Committee; the Committee con- measured at the J point relative to the QRS onset,
sidered that, given the retrospective nature of the anal- and all voltage measurements >1 mm (0.1 mV) were
ysis and the use of anonymized data, written informed rounded to the nearest 0.5 mm (0.05 mV); ST devia-
consent from patients was not needed. tions <1 mm (0.1 mV) were not taken into account. To
mitigate the potential influence of an unstable record-
ing baseline and interbeat ST and QRS variability on
Electrocardiographic Analysis our results, we considered an electrocardiographic
All ECGs were recorded at 25 mm/s speed, 10 mm/ criterion positive when it was present in >50% of the
mV amplitude. beats available in 1 lead.
The ECGs were analyzed by 2 independent car- The new electrocardiographic criteria evaluated
diologists from the coordinating center (Bellvitge in this study are (1) the presence of ST depression
Hospital), who were blinded to the clinical and an- ≥1 mm (0.1 mV) concordant with QRS polarity in
giographic data. In case of discordance, the evalu- any lead of the ECG (Figure 2 and Figure S1) and
ation of a third cardiologist was required. LBBB was (2) the occurrence of discordant ST deviation ≥1 mm
defined by the presence of QRS complex duration (0.1 mV) in leads with a low-voltage QRS (Figure 3,
>120 ms; QS or rS pattern in lead V1; R-wave peak Figure 4, and Figure S1). To evaluate low- voltage
time >60 ms in leads DI, V5, or V6; and absence QRS, we considered the voltage of the largest

Figure 2. ECG from a patient with acute myocardial infarction and culprit lesion in the right coronary artery, showing ST-
segment depression ≥1 mm (0.1 mV) concordant with negative QRS polarity in lead V5.
deflection of the QRS (ie, the R wave in leads with a Clinical Variables
predominantly positive QRS and the Q or S wave in In each patient, we recorded clinical and anthropo-
leads with a predominantly negative QRS), measured metric variables, laboratory tests, and electrocardio-
with respect to QRS onset; we defined this variable graphic and angiographic data. AMI was diagnosed
as max (R|S) voltage.5To accomplish this second cri- in the presence of either an acute coronary artery
terion, we needed to find the best cutoff value for occlusion (grade 0 of the thrombolysis in myocar-
max (R|S) voltage, below which any discordant ST dial infarction flow grading) or an acute coronary
deviation ≥1 mm (0.1 mV) would be regarded as ab- lesion with thrombolysis in myocardial infarction
normal and then support the diagnosis of AMI. This flow ≥1 associated with a troponin rise and fall
cutoff value was derived from the receiver operating above the 99th percentile upper reference limit.
characteristic (ROC) curves for max (R|S) voltages Coronary stenosis was considered acute when
ranging from 4 mm (0.4 mV) to 8 mm (0.8 mV). The signs of thrombosis or ulceration were identified by
best cutoff was defined by the highest area under the angiography.
ROC curve and the highest efficiency. The diagnosis of STEMI is based on electrocar-
We hypothesized that the highest sensitivity would diographic criteria that do not apply to patients with
be achieved by an algorithm that took into account LBBB. To test the diagnostic performance of the
all potential aspects of repolarization abnormalities in Modified Sgarbossa rules, Smith and coworkers5
LBBB, that is, concordant ST elevation, concordant ST elaborated a definition of STEMI equivalent based on
depression, and disproportionate discordant ST devia- angiographic findings and the amount of the release
tion in leads with a low-voltage QRS. of biomarkers of cardiac injury. To get closer to the
The Sgarbossa and Modified Sgarbossa Criteria concept of STEMI equivalent used in the Modified
were applied according to previously published defini- Sgarbossa Criteria, we elaborated a similar defini-
tions4,5 (Table S1). tion of STEMI equivalent (see Data S1) and tested

Figure 3. ECG from a patient with acute myocardial infarction and culprit lesion in the left circumflex artery, showing
discordant ST deviation ≥1 mm (0.1 mV) in 2 leads with a QRS voltage ≤6 mm (0.6 mV).
the diagnostic performance of the new electrocar- Reclassification Improvement index.12 The agree-
diographic criteria by including patients with STEMI ment between the 2 cardiologists who interpreted
equivalent in a separate analysis (see Data S1 and the ECGs was evaluated with the Cohen’s kappa
Table S2). coefficient. Differences were considered statisti-
cally significant at the 2-s ided P<0.05 level. The
Statistical Analysis statistical analysis was performed with STATA
Release 12 software (StataCorp LP, College
Continuous variables are presented as mean and
Station, TX).
SD or median and interquartile range. Categorical
variables are expressed as numbers and percent-
ages. Comparisons between groups were per-
formed using the t test or the Mann–Whitney U test RESULTS
for continuous variables and the chi-s quared test The study included 484 patients divided into 3
or Fisher’s exact test for categorical variables. The groups: (1) a derivation cohort formed by 163 pa-
95% CIs were obtained using Wald’s or Wilson’s tients who were referred for pPCI between October
method when appropriate. Sensitivity and speci- 2009 and December 2014, (2) a validation cohort in-
ficity of each electrocardiographic algorithm were cluding 107 patients referred for pPCI from January
compared using McNemar’s test. Global perfor- 2015 until June 2018, and (3) a control group of 214
mance of each algorithm was assessed by calcu- patients with LBBB and no suspected acute coro-
lating the efficiency and the area under the ROC nary syndrome. The 2 cardiologists who analyzed
curve. Efficiency is a parameter that expresses the the ECGs agreed completely on the evaluation of
percentage of correct classifications by a diagnos- the Sgarbossa criteria. There were 4 cases (1.5%) of
tic test, and it is calculated as follows: 100×(true disagreement concerning the Modified Sgarbossa
negatives+true positives)/all cases. Areas under Criteria and 2 cases (0.7%) of disagreement with
the ROC curve were compared using the algorithm the BARCELONA algorithm, all in patients referred
proposed by De Long et al.11 The added value of for pPCI. The Cohen’s kappa coefficient was 0.96
the new criteria was calculated by the Integrated for the Modified Sgarbossa criteria and 0.98 for the
Discrimination Improvement index and the Net BARCELONA algorithm.

Figure 4. ECG from a patient with acute myocardial infarction and culprit artery in the left main.
Discordant ST deviation ≥1 mm (0.1 mV) in leads with max (R|S) voltage ≤6 mm (0.6 mV) is present in leads III, aVR, and aVL.
Baseline Characteristics of Patients validation sample. As compared with those without

Referred for pPCI a diagnosis of AMI, patients with AMI were more
frequently men, had higher prevalence of diabetes
There were no significant differences in terms of cardiovas- mellitus, dyslipidemia, and prior myocardial infarc-
cular risk factors, cardiac history, and in-hospital death be- tion, as well as lower left ventricular ejection fraction
tween the derivation and the validation samples (Table 1). (Table 1). Clinical and angiographic details of pa-
AMI was diagnosed in 61 patients (37%) in the tients with AMI are presented in Table 2. There were
derivation cohort and in 40 patients (37%) in the no significant differences in AMI characteristics and

Table 1. Clinical Characteristics of the Study Population
Patients With Suspected AMI Referred for pPCI (N=270) Patients With No
Suspected AMI
Derivation Validation No AMI (Control Group)
Cohort (N 163) Cohort (N 107) P Value AMI (N 101) (N 169) P Value (N 214)
Age, y, median (IQR) 72 (62–78) 73 (65–82) 0.23 73 (64–80) 71 (63–79) 0.53 79 (72–85)
Sex, male 97 (60%) 60 (56%) 0.58 75 (74%) 82 (49%) <0.01 97 (46%)
Risk factors/comorbidities
Hypertension 125 (77%) 78 (73%) 0.48 81 (80%) 122 (72%) 0.14 179 (84%)
Dyslipidemia 97 (60%) 66 (62%) 0.72 76 (75%) 87 (51%) <0.01 128 (60%)
Diabetes mellitus 58 (36%) 45 (42%) 0.28 46 (46%) 57 (34%) 0.05 87 (41%)
Active smoker 29 (18%) 17 (16%) 0.68 24 (24%) 22 (13%) 0.02 19 (9)
Cardiac history
Known structural 73 (45%) 46 (43%) 0.77 45 (45%) 75 (44%) 0.98 99 (46%)
heart disease
Prior MI 24 (15%) 21 (20%) 0.29 24 (24%) 21 (13%) 0.02 25 (12%)
History of AF 28 (17%) 15 (14%) 0.49 11 (11%) 32 (19%) 0.08 65 (30%)
LVEF (%), 45 (35–60) 47 (35–60) 0.66 40 (33–50) 50 (35–60) <0.01 56 (46–60)*
median (IQR)
Admission data
Hospital stay (d), 4 (1–9) 5 (1–10) 0.03 6 (4–11) 2 (1–8) <0.01 NA
median (IQR)
In hospital death 11 (7%) 13 (12%) 0.13 15 (15%) 9 (5%) <0.01 NA
Chi squared or the Fisher exact test when appropriate were used to calculate differences between proportions; the Mann–Whitney U test was used to
calculate differences between medians. AF indicates atrial fibrillation; AMI, acute myocardial infarction; IQR, interquartile range; LVEF, left ventricular ejection
fraction; MI, myocardial infarction; NA, not available; and pPCI, primary percutaneous coronary intervention.
*LVEF was not available for 17 patients in the control group.
severity between the derivation and validation co- The Sgarbossa rule of ST depression limited to ECG
hort (Table 2). Overall, the clinical presentation of leads V1 to V3 had a sensitivity of 13%. By extending the
the AMI was often severe: 40% of patients were in analysis to concordant ST depression ≥1 mm (0.1 mV) in
Killip class III or IV, the median left ventricular ejec- any ECG lead the sensitivity increased to 51% (P<0.01)
tion fraction was 40%, and the in-hospital mortality still maintaining a 97% specificity (Table 4).
was 15%. The best cutoff value of max (R|S) voltage indi-
cating low-voltage QRS with disproportionate dis-
Baseline Characteristics of Patients With cordant ST deviation was 6 mm (0.6 mV). This max
(R|S) voltage gave the highest efficiency (86%) and
No Suspected AMI the highest area under the ROC curve (0.84), signifi-
The control group included 23 cases referred for cantly higher than other values (Figure 5). Thus, the
electrophysiological study after syncope, 96 pa- new criterion was positive in the presence of discor-
tients referred for pacemaker implantation and 95 dant ST deviation ≥1 mm (0.1 mV) in any ECG lead
patients attended at the emergency department. The with a max (R|S) voltage ≤6 mm (0.6 mV). Of note,
complete list of final diagnoses at the emergency in line with previous studies,7 patients with AMI had
department is reported in Table S3. The baseline lower QRS voltage (mean max [R|S] voltage 9.6 mm
characteristics of the control group are reported in or 0.96 mV versus 10.8 mm or 0.108 mV; P=0.01)
Table 1. Almost half of patients (46%) had structural and the median number of leads with max (R|S) volt-
heart disease, and the median left ventricular ejec- age ≤6 mm (0.6 mV) was higher in patients with AMI
tion fraction was 56%. (5 versus 3; P=0.02).
We tested several ECG algorithms incorporating
ECG Analysis in the Derivation Cohort the new criteria (Table 4). The best performance and
The Sgarbossa and Modified Sgarbossa rules the highest sensitivity were obtained by the algorithm
showed a high specificity (up to 98% for Sgarbossa that provided the most comprehensive approach to re-
score ≥3) but a low sensitivity (range, 26%–62%) polarization abnormalities in LBBB and included con-
for the diagnosis of AMI in the presence of LBBB cordant ST deviation >1 mm (0.1 mV) in any lead and
(Table 3). discordant ST deviation ≥1 mm (0.1 mV) in leads with

Table 2. Angiographic, Clinical, and Laboratory Data of Patients With Left Bundle Branch Block and Acute Myocardial
Infarction
All Patients, N=101 (%) Derivation Sample, N=61 (%) Validation Sample, N=40 (%) P Value
Acute occlusion (TIMI 0) 49 (49) 29 (48) 20 (50) 0.81

Acute lesion with TIMI 1–2 24 (24) 15 (25) 9 (23) 0.81
Acute lesion with TIMI 3 28 (28) 17 (28) 11 (28) 0.97
Multivessel disease* 57 (56) 37 (61) 20 (50) 0.29
Culprit artery 0.39
Left main 9 (9) 4 (7) 5 (14)
LAD territory 48 (48) 29 (48) 19 (48)
LCx territory 21 (21) 15 (25) 6 (16)
RCA territory 18 (18) 10 (16) 8 (22)
Intermediate artery 3 (3) 3 (5) 0 (0)
Killip class at admission 0.78
I 53 (52) 32 (52) 21 (53)
II 8 (8) 4 (7) 4 (11)
III 22 (23) 15 (25) 7 (18)
IV 18 (19%) 10 (17) 8 (21)
TnT or TnI ratio, median 171 (53–680) 194 (55–857) 149 (47–677) 0.52
(IQR)
CK-MB ratio, median (IQR) 23 (5–64) 23 (5–64) 23 (7–78) 0.94
The Pearson chi-squared or the Fisher exact test when appropriate was used to calculate differences between proportions; the Mann–Whitney U test was
used to calculate differences between medians. CK-MB indicates creatine kinase isoenzyme MB; LAD, left anterior descendending artery; LCx, left circumflex
artery; RCA, right coronary artery; STEMI, ST-segment–elevation myocardial infarction; TIMI, thrombolysis in myocardial infarction flow grade; TnI, troponin I;
and TnT, troponin T.
*Significant coronary stenosis in at least 2 coronary arteries.
max (R|S) voltage ≤6 mm (0.6 mV). This algorithm was The BARCELONA algorithm attained the highest
named BARCELONA algorithm and is described in de- sensitivity (95%), significantly higher (P<0.01) than
tail in Table 5. Sgarbossa and Modified Sgarbossa rules, as well
Table 3. Diagnostic Performance for AMI of the BARCELONA Algorithm and Previously Proposed Electrocardiographic
Algorithms
Sensitivity % Specificity % Efficiency %

Algorithm (95% CI) (95% CI) PPV % (95% CI) NPV % (95% CI) (95% CI) AUC ROC (95% CI)
Derivation cohort (N=163)

Sgarbossa score 34 (24–47) 98 (93–100) 91 (73–98) 71 (64–78) 74 (67–80) 0.66 (0.60–0.72)
≥3
Sgarbossa score 48 (36–60) 84 (76–90) 64 (50–77) 73 (64–80) 71 (63–77) 0.66 (0.59–0.73)
≥2
Mod. Sgarbossa III 62 (50–73) 91 (84–95) 81 (68–89) 80 (72–86) 80 (74–86) 0.77 (0.70–0.83)
Mod. Sgarbossa IV 51 (39–63) 96 (90–99) 89 (74–96) 77 (69–83) 79 (72–85) 0.73 (0.67–0.80)
Mod. Sgarbossa V 26 (17–38) 97 (92–99) 84 (62–95) 69 (61–76) 71 (63–77) 0.62 (0.56–0.67)
BARCELONA 95 (86–98) 89 (82–94) 84 (74–91) 97 (91–99) 91 (86–95) 0.92 (0.88–0.96)
Validation cohort (N=101)
Sgarbossa score 33 (20–48) 99 (92–100) 93 (69–99) 71 (61–80) 74 (65–81) 0.66 (0.58–0.74)
≥3
Sgarbossa score 40 (26–55) 85 (75–92) 62 (43–78) 70 (60–79) 68 (59–76) 0.63 (0.54–0.72)
≥2
Mod. Sgarbossa III 68 (52–80) 94 (86–98) 87 (71–95) 83 (73–90) 84 (76–90) 0.80 (0.72–0.88)
Mod. Sgarbossa IV 50 (35–65) 96 (88–99) 87 (68–96) 76 (66–84) 79 (70–85) 0.73 (0.65–0.82)
Mod. Sgarbossa V 28 (17–44) 97 (90–99) 85 (58–96) 70 (60–78) 72 (63–79) 0.63 (0.55–0.70)
BARCELONA 93 (80–97) 94 (86–98) 90 (78–96) 96 (88–98) 94 (87–97) 0.93 (0.88–0.98)
AMI indicates acute myocardial infarction; AUC, area under the curve; Mod. Sgarbossa III, IV and V Smith’s Modified Sgarbossa rule III, IV and V; NPV,
negative predictive value; PPV, positive predictive value; ROC, receiver operating characteristic; and STEMI, ST-segment-elevation myocardial infarction.

as the highest negative predictive value (97%), while indexes (both indexes showed P<0.01 comparing
maintaining 89% specificity (Table 3 and Table 6). The BARCELONA algorithm with Sgarbossa and Modified
global performance of the BARCELONA algorithm Sgarbossa rules).
was significantly better than previous algorithms: It
achieved the highest efficiency (91%) and the highest
area under the ROC curve (0.92), which was signifi- ECG Analysis in the Validation Cohort
cantly higher (P<0.01) than the ones obtained by the Sgarbossa and Modified Sgarbossa rules showed
Sgarbossa and Modified Sgarbossa rules (Figure 6). a high specificity (up to 99%) but a limited sensitivity
The BARCELONA algorithm also afforded a significant (28%–68%) (Table 3), confirming the results of the deri-
improvement in the ability to predict the occurrence vation cohort.
of an AMI, as shown by Integrated Discrimination A max (R|S) voltage value ≤6 mm (0.6 mV) also
Improvement and Net Reclassification Improvement achieved the highest efficiency (81%) and highest area
Table 4. Performance of New Criteria and Different Algorithms for the Diagnosis of AMI
Sensitivity Specificity% Efficiency%

Algorithm % (95% CI) (95% CI) PPV% (95% CI) NPV% (95% CI) (95% CI) AUC ROC (95% CI)
Derivation cohort (N=163)

Concordant ST depression 51 (39–63) 97 (92–99) 91 (77–97) 77 (69–83) 80 (73–85) 0.74 (0.67–0.80)
Disc-ST-max (R|S) ≤6 mm 77 (65–86) 91 (84–95) 84 (72–91) 87 (79–92) 86 (80–90) 0.84 (0.78–0.90)
(0.6 mV)
Any of
Conconcordant ST 85 (74–92) 90 (83–95) 84 (73–91) 91 (84–95) 88 (83–92) 0.88 (0.82–0.93)
depression
Disc-ST-max (R|S)
≤6 mm (0.6 mV)
Any of
Concordant ST 69 (56–79) 96 (90–99) 91 (80–97) 84 (76–89) 86 (80–90) 0.82 (0.76–0.89)
Depression
Concordant ST elevation
Any of
Disc-ST-max (R|S) 92 (82–96) 90 (83–95) 85 (74–92) 95 (85–94) 91 (85–94) 0.91 (0.86–0.96)
≤6 mm (0.6 mV)
BARCELONA algorithm 95 (86–98) 89 (82–94) 84 (74–91) 97 (91–99) 91 (86–95) 0.92 (0.88–0.96)
Validation cohort (N=101)
Concordant ST Depression 40 (26–55) 99 (92–100) 94 (72–99) 74 (64–82) 77 (68–84) 0.69 (0.61–0.77)
Disc-ST-max (R|S) ≤6 mm 60 (45–74) 94 (86–98) 86 (69–94) 80 (70–87) 81 (73–88) 0.76 (0.68–0.84)
(0.6 mV)
Any of
Conconcordant ST 78 (63–88) 94 (86–98) 89 (74–96) 88 (78–93) 88 (80–93) 0.85 (0.78–0.93)
depression
Disc-ST-max (R|S)
≤6 mm (0.6 mV)
Any of
Concordant ST 55 (40–69) 99 (92–99) 96 (79–99) 79 (69–86) 82 (74–88) 0.78 (0.70–0.86)
depression
Any of
Disc-ST-max (R|S) 83 (68–91) 94 (86–98) 89 (75–96) 90 (81–95) 90 (83–94) 0.88 (0.81–0.95)
≤6 mm (0.6 mV)
BARCELONA algorithm 93 (80–97) 94 (86–98) 90 (78–96) 96 (88–98) 94 (87–97) 0.93 (0.88–0.98)
Concordant ST depression, ST depression ≥1 mm (0.1 mV) concordant with QRS polarity, in any lead; Disc-ST-max (R|S)≤6 mm (0.6 mV), ST deviation
≥1 mm (0.1 mV) discordant with the QRS in any lead with max (R|S) voltage ≤6 mm (0.6 mV); Concordant ST elevation, ST. Elevation ≥1 mm (0.1 mV) concordant
with QRS polarity, in any lead ST, corresponding to Sgarbossa score of 5. AUC indicates area under the curve; NPV, negative predictive value; PPV, positive
predictive value; and ROC, receiver operating characteristic.

Figure 5. Diagnostic performance and receiver operating characteristic (ROC) curves for
the diagnosis of acute myocardial infarction using discordant ST deviation ≥1 mm (0.1 mV) in
leads with a low-voltage QRS.
We show the results of the best cutoffs for the max (R|S) voltage used to define low-voltage QRS, in
the derivation and in the validation cohort separately.

under the ROC curve (0.77) among the cutoff values Among these 21 patients, 2 had ST elevation ≥1 mm
tested to define a low- voltage QRS where dispro- (0.1 mV) concordant with QRS polarity, 1 had concord-
portionate discordant ST deviation ≥1 mm (0.1 mV) is ant ST depression ≥1 mm (0.1 mV), 17 had discordant
suggestive of AMI (Figure 5). Likewise, the validation ST deviation ≥1 mm (0.1 mV) in leads with max (R|S)
cohort confirmed that, extending the analysis of con- voltage ≤6 mm (0.6 mV), and 1 had both ST-segment
cordant ST depression ≥1 mm (0.1 mV) to any ECG elevation ≥1 mm (0.1 mV) concordant with QRS polar-
lead (instead of limiting it to leads V1–V3) resulted in a ity and discordant ST deviation ≥1 mm (0.1 mV) in leads
significant increase of diagnostic sensitivity (from 10% with max (R|S) voltage ≤6 mm (0.6 mV). Thus, in this
to 40%; P<0.01). control group, the majority (81%) of false-positive cases
The BARCELONA algorithm attained a 93% sen- of the BARCELONA algorithm were attributable to the
sitivity, which was significantly higher than that of the presence of discordant ST deviation ≥1 mm (0.1 mV) in
Sgarbossa and Modified Sgarbossa rules (P<0.01 leads with max (R|S) voltage ≤6 mm (0.6 mV).
and P<0.01, respectively). It also reached the high-
est negative predictive value (96%) and maintained a
94% specificity, which was not inferior to Sgarbossa DISCUSSION
and Modified Sgarbossa rules (Tables 3 and 7). The Main Findings and Strengths of the Study
global performance of the BARCELONA algorithm
This study shows that the diagnostic accuracy for AMI
was significantly better than previous algorithms: It
in the presence of LBBB was significantly improved by
achieved the highest efficiency (94%) and the highest
considering 2 new electrocardiographic criteria: (1) the
area under the ROC curve (0.93), which was signifi-
finding of ST depression ≥1 mm (0.1 mV) concordant
cantly higher (P<0.01) than the ones obtained by the
with QRS polarity in any ECG lead and (2) the existence
Sgarbossa and Modified Sgarbossa rules (Figure 6).
of ST deviation ≥1 mm (0.1 mV) discordant with QRS
polarity in any ECG lead with low-voltage QRS, with
Diagnostic Yielding of the ECG in the the optimal cutoff for low-voltage QRS established as
Entire Cohort of Patients Referred for pPCI max (R|S) voltage ≤6 mm (0.6 mV).
The application of a Sgarbossa score ≥3 and the To our knowledge, this is the largest cohort of pa-
Modified Sgarbossa rules in our entire cohort of 270 tients with LBBB referred for pPCI used to evaluate elec-
patients with LBBB referred for pPCI (101 diagnosed trocardiographic algorithms to diagnose AMI. Patients
with AMI) would have missed 67 and 36 patients with with LBBB referred for pPCI are the target population
AMI, respectively. By contrast, the BARCELONA algo- that could benefit the most from an improved electro-
rithm would have missed only 6 patients. cardiographic diagnosis of AMI. Because of the lack
The influence of coronary reperfusion on the elec- of a reliable electrocardiographic diagnosis of AMI,
trocardiographic algorithms could be evaluated in 75 these patients are often overtreated. Indeed, in our
patients with AMI in whom an ECG recorded within the study, 63% of patients were unnecessarily exposed to
first 48 hours after pPCI was available. After pPCI, the an emergent reperfusion protocol, which has inherent
BARCELONA algorithm became negative in 93% of pa-
tients with AMI who were positive before reperfusion. Table 6. Comparison of the Main Algorithms Regarding
Sensitivity and Specificity for AMI in the Derivation Sample
Control Population Specificity

Sensitivity % (95%
The BARCELONA algorithm was positive in 21 of Algorithm % (95% CI) P Value CI) P Value
214 patients (10%), thus achieving a 90% specificity.
BARCELONA 95 (86–98) 89 (82–94)
algorithm
Table 5. Definition of the BARCELONA Algorithm to Sgarbossa score 34 (24–47) <0.01 98 (93–100) <0.01
Diagnose AMI in the Presence of LBBB ≥3
Sgarbossa score 48 (36–60) <0.01 84 (76–90) 0.33
The BARCELONA algorithm is positive if any of the following criteria are
≥2
present:
Modified 62 (50–73) <0.01 91 (84–95) 0.69
(1) ST deviation ≥1 mm (0.1 mV) concordant with QRS polarity in any
Sgarbossa rule III
ECG lead, thus including either:
• ST depression ≥1 mm (0.1 mV) concordant with QRS polarity, in any Modified 51 (39–63) <0.01 96 (90–99) 0.07
ECG lead. Sgarbossa
• ST elevation ≥1 mm (0.1 mV) concordant with QRS polarity, in any rule IV
ECG lead (Sgarbossa score 5).
Modified 26 (17–38) <0.01 97 (92–99) 0.04
(2) ST deviation ≥1 mm (0.1 mV) discordant with QRS polarity, in any Sgarbossa rule V
lead with max (R|S) voltage ≤6 mm (0.6 mV).
The reference value to calculate the P value is the BARCELONA algorithm.
AMI indicates acute myocardial infarction; and LBBB, left bundle branch The P value is obtained with McNemar’s test. AMI indicates acute myocardial
block. infarction.

Figure 6. Receiver operating characteristic (ROC) curves of ECG algorithms for the diagnosis
of acute myocardial infarction in the presence of left bundle branch block, in the derivation and
validation sample.
risks and an elevated economic cost. Moreover, the AMI, overcoming the limitation of some previous stud-
availability of angiographic data in patients referred ies where the diagnosis of AMI was confirmed only by
for pPCI allowed us to establish a reliable diagnosis of cardiac biomarkers.4

Table 7. Comparison of the Main Algorithms Regarding In patients with LBBB, it has been demonstrated
Sensitivity and Specificity for AMI in the Validation Sample that acute ischemia is associated with an increase in
Sensitivity Specificity the magnitude of ST deviations discordant with QRS
Algorithm % (95% CI) P Value % (95% CI) P Value polarity7,13 so that they become disproportionately
BARCELONA 93 (80–97) 94 (86–98) greater than would be expected by the voltage of the
Sgarbossa 33 (20–48) <0.01 99 (92–100) 0.08
QRS in the corresponding lead. By using a new ap-
score ≥3 proach, we could identify a max (R|S) voltage of 6 mm
Sgarbossa 40 (26–55) <0.01 85 (75–92) 0.08 (0.6 mV) as the best cutoff for disproportionate discor-
score ≥2 dant ST deviations ≥1 mm (0.1 mV) suggestive of AMI.
Smith III 68 (52–80) <0.01 94 (86–98) >0.99 The BARCELONA algorithm incorporated a com-
Smith IV 50 (35–65) <0.01 96 (88–99) 0.32 prehensive approach to repolarization abnormalities
Smith V 28 (17–44) <0.01 97 (90–99) 0.16 in patients with LBBB by including concordant ST de-
The reference value to calculate the P value is the BARCELONA algorithm.
viations ≥1 mm (0.1 mV) in any lead and discordant
The test used to calculate the P value is the McNemar’s test. AMI indicates ST deviations in leads with max (R|S) voltage ≤6 mm
acute myocardial infarction. (0.6 mV). This algorithm significantly improved the sen-
sitivity of the ECG to diagnose AMI in patients with
The type of study (cohort study) also permitted cal- LBBB, achieving similar results to those obtained by
culation of positive predictive value and negative pre- the ECG in patients without LBBB.14 It also had a high
dictive value, which could not be performed in previous negative predictive value: When the algorithm is nega-
case-control studies.4,5 This was an “all comers” study, tive, the probability of AMI seems very low.
as we did not select or exclude patients with certain The BARCELONA algorithm also had good spec-
clinical variables. Therefore, the results may be widely ificity and positive predictive value: only 9% of pa-
applicable to patients with LBBB and suspected AMI. tients without AMI would have still been transferred
Finally, the specificity of the proposed criteria was also for emergent reperfusion by using the new algorithm.
tested in a control population without suspected acute This percentage is in agreement with the prevalence
coronary syndrome. of false-positive activation of the pPCI protocol in the
general population, including patients without LBBB.15
Moreover, the BARCELONA algorithm confirmed
Electrocardiographic Diagnosis of AMI in a 90% specificity in a large cohort of patients with
the Presence of LBBB LBBB without suspected acute coronary syndrome.

Our results show that concordant ST deviations are Of note, among patients with LBBB and AMI in-
extremely specific for AMI. This was already known for cluded in the present study, there was a wide range of
concordant ST elevation ≥1 mm (0.1 mV) (Sgarbossa culprit arteries, including all major coronary branches
score 5) but had not been demonstrated for concord- as well as the left main. Thus, the good performance
ant ST depression ≥1 mm (0.1 mV) in any lead. As of the new algorithm could apply to any AMI location.
described in Table 1 in their manuscript,4 Sgarbossa Finally, this new algorithm is simpler as compared with
and colleagues analyzed the ST- segment concord- the Modified Sgarbossa Criteria and could be widely
ance or discordance with QRS polarity only for ST el- applied without determining a relevant delay in diagno-
evation. By contrast, they evaluated the presence of sis and reperfusion.
ST depression in any lead without correlating it with
QRS polarity. They found that ST depression in leads
V1 to V3 was suggestive of AMI, since leads V1 to LBBB and Suspected AMI: To Treat or to
V3 generally display a negative QRS in patients with Wait?
LBBB. However, such analysis without correlating ST The presence of LBBB in patients with ischemic symp-
depression with QRS polarity could miss the clinical toms has traditionally been considered an ECG equiv-
relevance of concordant ST deviations occurring in alent to ST-segment elevation and the 2017 European
those ECG leads that can have either a negative or Society of Cardiology guidelines16 still recommend
a positive QRS in different patients with LBBB. In our emergent reperfusion in such cases.
series, when concordant ST depression was present, However, increasing evidence suggests that LBBB
it occurred in leads other than V1 to V3 in the vast is a major cause of false activation of the pPCI pro-
majority of patients with AMI, and these patients would tocol.1 In view of these findings, the 2013 American
have been missed by the Sgarbossa rules. Thus, we guidelines stated that LBBB should not be considered
confirmed the hypothesis that by evaluating concord- diagnostic of AMI in isolation.17
ant ST depression in any lead, we could improve the Until a reliable diagnosis of AMI with LBBB is avail-
sensitivity of the ECG to detect ischemia in different able, both strategies have major drawbacks. On the
myocardial regions. one hand, if LBBB is considered an equivalent to

ST-segment elevation, a majority of patients who have confirmed in a large and heterogeneous control group
not experienced an AMI are unnecessarily exposed to of patients without suspected AMI.
the aggressive and costly protocol of emergent reper-
fusion. This was also confirmed in our cohort where,
among patients with LBBB referred for pPCI, only 37% ARTICLE INFORMATION
actually had an AMI (a result in line with previous report Received December 9, 2019; accepted April 14, 2020.
from other groups).1 On the other hand, if the pPCI pro- Affiliations
tocol is not directly activated in patients with LBBB and From Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
ischemic symptoms, the high-risk subgroup of patients (A.D.M., M.R., A.A.-S., C.S.-S., J.A.G.-H., Á.C., I.A.); Cardiology Department,
Hospital de la Santa Creu I Sant Pau, IIB-Santpau, CIBERCV, Universitat
with LBBB and AMI may not receive timely reperfu- Autonoma de Barcelona, Spain (J.C., A.S., E.S.-G.); Cardiology Department,
sion treatment with potential consequences over their Germans Trias i Pujol University Hospital (A.B.G., B.T., P.C.) and Cardiology
prognosis. Department, Hospital Clinic (J.T.O.-P., J.R., M.M.), CIBERCV, Barcelona,
Spain.
These considerations highlight the urgent need for
new ECG criteria to diagnose AMI in the presence of Acknowledgments
LBBB and underline the clinical and also economic We thank the Bellvitge Institution of Biomedical Investigation (IDIBELL) and
the CERCA Programme/Generalitat de Catalunya for institutional support.
importance of the present findings to improve the effi-
ciency of pPCI networks. Sources of Funding
Recently, clinical algorithms based on the hemo- None.
dynamic status, on cardiac biomarkers and echo- Disclosures

cardiographic findings have also been proposed to None.
improve the management of patients with LBBB and Supplementary Materials
suspected AMI.18,19 However, these algorithms may Data S1
be limited by the high prevalence of initially elevated Tables S1–S3
Figure S1
cardiac biomarkers among patients with LBBB with- References 20–25
out AMI2 and by the limited echocardiographic avail-
ability in small hospitals and emergency services. The
possibility to achieve a reliable electrocardiographic
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SUPPLEMENTAL MATERIAL
Data S1.
Supplemental Methods
Definition of a STEMI equivalent
Patients with acute coronary occlusion were considered to have a STEMI equivalent.
However, between one quarter and one third of STEMI patients have no complete acute
occlusion of the culprit artery at the time of pPCI.20,21 Therefore the definition of a STEMI
equivalent needs to be extended also to patients with acute non-occlusive coronary lesions. In
cases of patent culprit artery, cardiac biomarkers may be a useful discriminator since STEMI is
associated with higher biomarker release than non-STEMI (NSTEMI).22 Several studies
analyzed biomarkers ratio (the peak level divided by the upper normal limit): 25% of STEMI
patients were found to have a cardiac troponin I (cTnI) ratio lower than 4522 and 11% fitted in
a category of low cardiac troponin (cTn) defined by a lower limit of cTn ratio of 10.23 Creatine
kinase isoenzyme MB (CK-MB) ratio is usually lower than cTnI22,24,25 ratio and the upper limit
of the first quartile for CK-MB ratio in STEMI was found to be 8 in a previous study that
included the largest population investigated so far.22
In the present study patients with acute non-occlusive coronary lesions were considered
to have a STEMI if their cardiac troponin I (cTnI) or cardiac troponin T (cTnT) ratios were ≥10
or when the creatine kinase MB isozyme (CK-MB) ratio was ≥5.
Supplemental Results
STEMI equivalent
In the derivation cohort, out of 61 patients with AMI, 58 (95%) had a STEMI
equivalent; similar results were obtained in the validation cohort, where, among the 40
patients with AMI, 38 (95%) had a STEMI equivalent. Both in the derivation and
validation cohort, the BARCELONA algorithm showed the highest sensitivity, highest
NPV and highest efficiency for the diagnosis of a STEMI equivalent (Table S3).
Moreover, both in the derivation and in the validation cohort the BARCELONA
algorithm had the highest area under the ROC curve, significantly higher (p<0.01) than
previous ECG rules.

Table S1. Definition of previously described algorithms.
Algorithm Criteria
Sgarbossa score ≥3 - ST elevation ≥1mm (0.1mV) in any lead concordant with the QRS
and/or
- ST depression ≥1mm (0.1mV) in leads V1-V3
Sgarbossa score ≥2 - Sgarbossa score ≥3
and/or
- ST elevation ≥5mm (0.5mV) in any lead, discordant with the QRS
Modified Sgarbossa rule III - Sgarbossa score ≥3
and/or
- ST elevation/S ≤-0.25 in any lead with ST elevation ≥1mm (0.1mV)
Modified Sgarbossa rule IV - Sgarbossa score ≥3
and/or
- ST deviation/S or R ≤-0.3 in any lead with ST deviation ≥1mm (0.1mV)
Modified Sgarbossa rule V - ST deviation/S or R ≤-0.3 in any lead with ST deviation ≥1mm (0.1mV)
Table S2. Diagnostic performance of different ECG algorithms for the diagnosis of
STEMI equivalent.
Algorithm Sensitivity Specificity PPV NPV Efficiency AUC ROC

% (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) (95% CI)
Derivation cohort (N 163)
Sgarbossa score ≥3 36 (25-49) 98 (93-100) 91 (73-98) 74 (66-80) 76 (69-82) 0.67 (0.61-0.74)
Sgarbossa score ≥2 50 (38-63) 85 (77-90) 64 (50-77) 75 (67-82) 72 (65-79) 0.67 (0.60-0.75)
Mod. Sgarbossa III 66 (53-76) 91 (85-95) 81 (68-90) 83 (75-89) 82 (76-87) 0.78 (0.71-0.85)
Mod. Sgarbossa IV 53 (41-66) 96 (91-99) 89 (74-96) 79 (71-85) 81 (74-86) 0.75 (0.68-0.82)
Mod. Sgarbossa V 28 (18-40) 97 (92-99) 84 (62-95) 71 (63-78) 72 (65-78) 0.62 (0.56-0.68)
BARCELONA 95 (86-98) 87 (79-92) 80 (69-88) 97 (91-99) 90 (84-93) 0.91 (0.86-0.95)
Validation cohort (N 107)

Sgarbossa score ≥3 34 (21-50) 99 (92-100) 93 (69-99) 73 (63-81) 76 (67-83) 0.67 (0.59-0.75)
Sgarbossa score ≥2 42 (28-58) 86 (75-92) 62 (43-78) 73 (62-81) 70 (61-78) 0.64 (0.55-0.73)
Mod. Sgarbossa III 68 (53-81) 93 (84-97) 84 (67-93) 84 (74-91) 84 (76-90) 0.80 (0.72-0.88)
Mod. Sgarbossa IV 50 (35-65) 94 (86-98) 83 (63-93) 77 (67-85) 79 (70-85) 0.72 (0.64-0.81)
Mod. Sgarbossa V 27 (15-43) 96 (88-99) 77 (50-92) 71 (61-79) 72 (63-79) 0.61 (0.54-0.69)

BARCELONA 95 (83-99) 93 (84-97) 88 (75-95) 97 (90-99) 94 (87-97) 0.95 (0.91-0.99)
CI, confidence interval; NPV, negative predictive value; PPV, positive predictive value; STEMI, ST elevation
myocardial infarction; Mod. Sgarbossa III, IV and V, Smith’s Modified Sgarbossa rule III, IV and V.
Table S3. Within the control group of patients with LBB without suspected AMI, 95
patients were included after a visit at the emergency department due to symtpoms other
than chest pain and with a final diagnosis different from acute coronary syndrome.
Diagnosis N (%)
Decompensated heart failure 16 (17%)
Syncope/Lipothymia 10 (11%)
Atrial fibrillation/flutter 9 (9%)
Decompensated COPD 9 (9%)
Stroke/TIA 5 (5%)
Trauma 3 (3%)
Anemia 3 (3%)
Pneumonia 3 (3%)
Seizures 3 (3%)
Subarachnoid hemorrage 3 (3%)
Gastritis 3 (3%)
Rectal bleeding 2 (2%)
Lower limb ischemia 2 (2%)
Hepatic encephalopathy 2 (2%)
Gastroenteritis 2 (2%)
Perianal abscess 2 (2%)

Acute kidney failure 2 (2%)
Sepsis 2 (2%)
Complications of neoplasm 2 (2%)
Urinary tract infection 2 (2%)
Hemoptisis 1 (1%)
Dehydration 1 (1%)
Acute confusion 1 (1%)
Peripheral vertigo 1 (1%)
Acute pancreatitis 1 (1%)
Back pain 1 (1%)
Bipolar disorder 1 (1%)
High INR (>6) 1 (1%)
Acute colangitis 1 (1%)
Deep vein thrombosis 1 (1%)
The final diagnosis at the emergency department of these patients is reported in the table.
COPD, chronic ostructive pulmonary disease; TIA, transient ischemic attack; INR, international
normalized ratio.
Figure S1. ECG from a patient with acute myocardial infarction and culprit lesion in the
left anterior descending artery. Concordant ST depression ≥1mm (0.1mV) is present in lead
V4. Discordant ST deviation ≥1mm (0.1mV) in a lead with max (R|S) voltage ≤6mm (0.6mV)
is present in lead V5. In this figure the Modified Sgarbossa criteria could be considered
positive in lead V5. However, the ST depression in lead V5 is just below 2mm (0.2mV) and
falls between 1.5mm (0.15mV) and 2mm (0.2mV); considering this ST deviation 1.5mm
(0.15mV) or 2mm (0.2mV) make a complete difference with respect to the Modified Sgarbossa
criteria that become either negative or positive. This example shows how the Modified
Sgarbossa criteria, which are based on an exact measurement of both QRS amplitude and ST
deviation, may be difficult to evaluate, especially in the setting of emergency care. By contrast,
the BARCELONA algorithm, based on simpler cut-offs, may be easier to evaluate and in this
case it was undoubtedly positive.


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Journal of the American Heart Association

New Electrocardiographic Algorithm for the

See Editorial by Macfarlane

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155731

Second, we considered as a positive criterion for

The “Codi IAM” network9 in Catalonia (Spain) provides

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155732

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155733

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155734

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155735

Baseline Characteristics of Patients validation sample. As compared with those without

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155736

Table 1. Clinical Characteristics of the Study Population

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155737

Acute occlusion (TIMI 0) 49 (49) 29 (48) 20 (50) 0.81

Sensitivity % Specificity % Efficiency %

Derivation cohort (N=163)

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155738

Sensitivity Specificity% Efficiency%

Derivation cohort (N=163)

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.0155739

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.01557310

Control Population Specificity

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.01557311

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.01557312

the Presence of LBBB LBBB without suspected acute coronary syndrome.

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.01557313

dynamic status, on cardiac biomarkers and echo- Disclosures

Prasad A. Utility of left bundle branch block as a diagnostic criterion for

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.01557314

J Am Heart Assoc. 2020;9:e015573. DOI: 10.1161/JAHA.119.01557315

Definition of a STEMI equivalent

included the largest population investigated so far.22

or when the creatine kinase MB isozyme (CK-MB) ratio was ≥5.

previous ECG rules.

Algorithm Sensitivity Specificity PPV NPV Efficiency AUC ROC

Sgarbossa score ≥2 50 (38-63) 85 (77-90) 64 (50-77) 75 (67-82) 72 (65-79) 0.67 (0.60-0.75)

Mod. Sgarbossa IV 53 (41-66) 96 (91-99) 89 (74-96) 79 (71-85) 81 (74-86) 0.75 (0.68-0.82)

Mod. Sgarbossa V 28 (18-40) 97 (92-99) 84 (62-95) 71 (63-78) 72 (65-78) 0.62 (0.56-0.68)

BARCELONA 95 (86-98) 87 (79-92) 80 (69-88) 97 (91-99) 90 (84-93) 0.91 (0.86-0.95)

Validation cohort (N 107)

Sgarbossa score ≥2 42 (28-58) 86 (75-92) 62 (43-78) 73 (62-81) 70 (61-78) 0.64 (0.55-0.73)

Mod. Sgarbossa IV 50 (35-65) 94 (86-98) 83 (63-93) 77 (67-85) 79 (70-85) 0.72 (0.64-0.81)

Mod. Sgarbossa V 27 (15-43) 96 (88-99) 77 (50-92) 71 (61-79) 72 (63-79) 0.61 (0.54-0.69)

BARCELONA 95 (83-99) 93 (84-97) 88 (75-95) 97 (90-99) 94 (87-97) 0.95 (0.91-0.99)

Perianal abscess 2 (2%)

case it was undoubtedly positive.

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