ESC Congress 2007 .


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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. National Registry of Mexican Society of Cardiology.
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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 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

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BACKGROUND-1 Bundle branch piece (BBB) right on time amid intense myocardial localized necrosis (AMI) is regularly viewed as high hazard for mortality In the Fibrinolytic Therapy Trialists\' meta-examination, patients with BBB at randomization had a 35-day death rate of 24% without and 19% with fibrinolytic treatment. The studies included saw no difference amongst rigth package branch square (RBBB) and left package branch piece (LBBB) and did not indicate whether the BBB was new or old Different sorts of BBB happening amid the underlying hours of AMI may have diverse prognostic ramifications that are independient of another prognostic elements ESC Congress 2007

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BACKGROUND-2 Development of new BBB notwithstanding brief fibrinolytic treatment may mean a broad and progressing AMI. A few sorts of BBB may reflect bigger infarct regions, showing that these patients may profit by more forceful reperfusion treatment Until our knowledgment the visualization of RBBB in patients with intense coronary disorders is misty Reference : European Heart Journal (2006)27,21-28 ESC Congress 2007

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METHODS-1 The RENASICA II Design outline Is the biggest national registry of ACS selected 8,098 patients with definite conclusion of ACS ST rise (STE) or non-ST height (NSTE) secundary to ischaemic coronary illness and intended to portray an impartial and delegate populace The patients were enrrolled in 66 essential and tertiary Mexican Hospitals and for quality control criteria af Alpert were utilized. The healing facilities shifted regarding access to nearby cardiovascular catheterization, number of intense care overnight boardinghouses kind of work on setting with a point of stlablishing a delegate as opposed to particular study populace ESC Congress 2007

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METHODS – 2 : Patients with ST intense myocardial localized necrosis (AMI) with LBBB or RBBB were looked at as far as in-clinic result and major cardiovascular unfavorable occasions (MACE) , cardiovascular demise, myocardial dead tissue (MI) and repetitive ischaemia patients with indications accelerated by anemia,hypertension, heart disappointment, and so forth were avoided BBB was characterized as de the QRS length of 0.12 sec in precence sinus or supraventricular mood Multivariable Analysis was performed to recognize in doctor\'s facility mortality chance among RBBB and LBBB with MACE Odd proportion (OR) and certainty interims 95% (CI) ESC Congress 2007

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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 term > 0.12 seg. 4. Finish Register Form – Signed IC EXCLUTION (1) 1. Non Ischaemic CP encouraged by secundary cause as frailty, heart disappointment or hypertension 2. Past BBB 3. Pacemaker rythm ESC Congress 2007

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QUALITY To guarantee quality control of registry information the accompanying criteria created by Alpert were connected in RENASICA II: Standarizad definitions and all members were familiarizad Careful healing facilities determination Hospitals affirmed registry information accumulation handle All gathered information were accounted for Original data,electronic entries were concentrated An expert analyst broke down the information All information and electronic entries were analyzed by the focal information administration Principal examiner and directing advisory group keep regulatory request, arbitrated contradictions and energized convenient accommodation of records and information investigation. ESC Congress 2007

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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 RESULTS 4,555 patients with STE AMI were examined in this substudy Of them 7% had RBBB and 5% LBBB There were not factual contrasts in both gatherings among matured, sexual orientation pattern qualities, onset side effects, ischemic time, AMI area, Killip utilitarian class, ventricular brokenness, and reperfusion procedures. Patients with mediocre or front STE AMI with RBBB had most noteworthy mortality and relationship with MACE ( OR 1.70, CI 1.19 – 2.42, p< 0.003 contrasted with LBBB. ESC Congress 2007

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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 n = 8,098 Patients with ACS UA/Non ST AMI* n = 3,445 (40%) STE AMI** n = 4,555 (53%) Unspeciphic Chest Pain n = 625 (7%) RBBB n= 318 (7%) LBBB n= 227 (5%) * UA/Non ST AMI = Unstable Angina No ST height intense myocardial dead tissue ** STE AMI = ST rise intense myocardial localized necrosis ESC Congress 2007

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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 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% ESC Congress 2007

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Baseline Characteristics-1 Characteristic RBBB (n=318) LBBB (n=227) Age-years-middle 66.7 67.3 Men (%) 76 71 Hypertension (%) 55 59 Hyperlipidemia (%) 27 26 Current/previous smoker (%) 63 66 Diabetes (%) 48 47 Previous AMI (%) 23 35 all p = NS ESC Congress 2007

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Baseline Characteristics-2 Characteristic RBBB (n=318) LBBB (n=227) AMI area (%) Anterior Inferior 32 23 16 235 54 16 13 168 38 12 9 K Killip I (n =) II III IV All p = NS ESC Congress 2007

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TREATMENT Medication RBBB (n=318) LBBB (n=227) Reperfusion Strategy Lytic (%) Primary PTCA (%) 23 20 32 23 Clopidogrel (%) 44 38 88 89 ASA (%) 51 Beta Bloq.(%) 59 64 IECA/ARB (%) 14 13 Statins (%) all p = NS ESC Congress 2007

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Outcomes in Hospital Comparison in both BBB and MACE ESC Congress 2007 30 20 10 0 RBBB LBBB % * P esteem = ns

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0.5 1.0 2.0 5.0 10 100 IN HOSPITAL MORTALITY PREDICTORS IN STEMI A SUBSTUDY OF RENASICA II (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) discoveries ECG LBBB RBBB 3 rd degree AV piece ST Depresion in > 3 ECG leads calculated regresion in mortality indicators ESC Congress 2007

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Clinical Implications The higher mortality and higher occurrence of RBBB found in patients with front AMI might be axplained by: Septal ischaemia from a more proximal left plunging corridor impediment (before the substantial septal branch) The course of the rigth package branch navigating the septum towards the peak. Constraints As in every single clinical trial, a determination predisposition could have happened in RENASICA II bringing about under-representation of high hazard patients (counting those with RBBB going with front AMI) in the trial partner. ESC Congress 2007

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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 going with front or substandard AMI at presentation was an independient indicator of high in healing facility mortality. These electrocardiographics elements ought to be considered in hazard stratification to distinguish high-chance patients ESC Congress 2007

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