Sgarbossa's Criteria

[fiznat]

Speaking of experience...

Anyone have any good examples of AMI in the setting of LBBB with positive concordance? I'd like to see what it looks like, and maybe we can discuss it a little bit.

[fiznat]

Okay I've found a few EKGs on my own. Let's discuss. Which of these would you guys call AMI using Sgarbossa's criteria? (Hint: only one of them, according to the website where I found them, is listed with a Dx of AMI.)

(sorry for the large images)

#1

#2

#3

**A question. Might spoil the answer for those interested in figuring it out for themselves:**

What I dont understand about this criteria is that on the outset it seems to only be specific for certain areas of the EKG. ST elevations in concordance with the QRS requires a dominant R wave, which is normally only present in just a few of the chest leads (V4, V5, V6) and most of the limb leads. Unless there is some serious axis/rotational issue or wacky origin, the S wave is prominent in the other leads and we will never see ST "elevations" that are in concordance with what is normally a primarily negative QRS there. The criteria requires 5 millimeters of elevation in leads in which the QRS would be discordant. That seems like a pretty big MI. Does this mean that Sgarbossa is not very specific for anterior and septal AMI?

[emstrainer]

ECG #2 has Concordance in the Lateral Leads .... This is the AMI Patient. I once had the opportunity to spend a day with Dr. Tomas Garcia (Author of 12 Lead ECG: The Art of Interpretation) and he spoke the next day at an all day 12 Lead Class. He has alot of great information ...but he stressed that Concordance is BAD .... He did not give any example of Good Concordance ..... It is always in the Company of AMI .... That has always stuck with me.

I have attached another example of Concordance ..... This time in a patient with an Implanted Pacemaker. Obviously if the QRS is >.12 we teach the Paramedics that they cannot distinguish STEMI .... but when there is Concordance it is a different story. This particular patient was lucky enough that the ED Doc liked the report and did activate the Cath Lab ...The patient did get their intervention and had a great outcome.

EEP Online - Pacer ECG

Jason Kinley

[fiznat]

I have attached another example of Concordance ..... This time in a patient with an Implanted Pacemaker.

That is an interesting EKG. I haven't seen a lot of these, but I think I would have a hard time activating a cath lab based on that strip alone.

Does Sgarbossa's apply for paced rhythms? I have only found it in reference to LBBB. I wonder if things may be a little bit different if the axis is way off, as it is with this ventricularally-paced rhythm. There is concordance in V1-V3ish, but only because the direction of depolarization is altered due to the low (caudal) origin of the rhythm. The S wave should be prominent there, not the R. Is this still real concordance? I'm not trying to be sarcastic here, I'm asking because I dont know.

Also there are no reciprocal changes at all, and the real height of the ST elevation may be confounded by retrograde atrial depolarization. There are a lot of things here that blur the image of true AMI. If activating the cath lab is such a stretch, an act of trust as 'Zilla mentioned, I really think I would have trouble making a firm decision on this one without a few other key findings.

I'd be interested to hear what other people think.

**Also, yes, EKG #2 was listed as the one with the AMI. *high five* :wink: #3, though, has some pretty tall (albeit discordant) elevations in the anterio-septal leads. Maybe close to the 5mm criteria?

[Dustdevil]

ECG #2 has Concordance in the Lateral Leads .... This is the AMI Patient.

I don't know a thing about Sgarbossa's Criteria, even after reading this thread three times. :? However, it is a no brainer that #2 is the AMI, even at a casual glance. I didn't need Sgarbossa's Criteria, a rate, rhythm, axis, calipers, Beck's Triad, Turners' Sign, the Rule of Nines, or even 12 leads to tell me that. Some things are just obvious.

Plus 5 for a great topic though. And welcome to the forum, Jason.

[emstrainer]

Dust Devil .... There is ST Elevation in all 3 examples above. Please share whay you thought #2 was a Slam Dunk .... You may understand Sgarbossa's Criteria better than you thought ...

And I'm glad to participate in good discussion ....

Jason Kinley

[Dustdevil]

Dust Devil .... There is ST Elevation in all 3 examples above. Please share whay you thought #2 was a Slam Dunk .... You may understand Sgarbossa's Criteria better than you thought ...

lol... well, there is ST elevation, and then there is ST ELEVATION. The ST ELEVATION in V5 and V6 are so profound as to jump up and grab you by the throat. It is the most prominent feature in that particular EKG, whereas the BBB is the most prominent feature in the other two. On those two, given the symptomology, I would still have been carefully looking to R/O an AMI with other tests and criteria. However, on number 2, I would be headed for the cath lab with confidence.

[Just Plain Ruff]

Dust I agree. number two just shouted "GEt me to cath lab"