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Sgarbossa Criteria for Ventricular Paced Rhythm

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How can we identify STEMI in patients with ventricular paced rhythm?

Can we use the Sgarbossa Criteria? Below you’ll find what’s most likely (and hopefully) the silliest, catchiest and nerdiest talk on this topic recorded at the ECG masterclass from SWEETS2019. In it, Jonathan Ilicki, Alex Szeps and Elena Sgarbossa delve into how we best assess these patients. Here, first, is a bit more detail.

So what are the Sgarbossa criteria?

The Sgarbossa Criteria are three ECG rules that were developed by Dr Sgarbossa in 1996:

  • Concordant ST elevation ≥ 1mm in a lead with a positive QRS complex (5 points)
  • ST depression ≥ 1 mm in V1, V2 or V3 (3 points)
  • Discordant ST elevation ≥ 5 mm in a lead with a negative QRS complex (2 points)

    • 3 or more points has been shown to be highly specific (98%) for ACS in patients with LBBB​[1]​. Life on the Fast Lane has a great ECG database with a page about the Sgarbossa criteria.

    So can I use this for patients with ventricular paced rhythm (VPR)?

    There is limited research (key articles below​[2–7]​), but what has been published to date indicates the criteria are very specific, but not sensitive for ACS in patients with VPR​[8]​ (open access here).

    Amal Mattu has a great ECG resource called ECG Weekly. Here is an episode where he discusses using the Sgarbossa Criteria for Ventricular Paced Rhythm.

    This sounds great! Could anything possibly be better than the Sgarbossa criteria?

    Interestingly, the Smith-modified Sgarbossa Criteria have recently been shown to have superior sensitivity and specificity to the original criteria​[9]​. It wasn’t included in the presentation as it’s tricky to fit the phrase “Smith-modified Sgarbossa Criteria” into a song…

    Dr Smith is an ECG wizard (and also a really nice guy) and has a great blog entirely focused on how to get better at assessing ECGs. Here are a couple of posts on assessing for ACS/ACO in ECGs with VPR:

    • Anterior MI in paced rhythm
    • Ventricular paced rhythm and chest pain
    • Case illustrating false positive Sgarbossa criteria
    • Ventricular paced rhythm and chest pain again
      • Enough of that – here’s the talk
      https://youtu.be/mtqhnmasaiA
      Audio

      Slides
      Credits
      • Alex Szeps – find his music here on Spotify!
      • Elena Sgarbossa – for impactful research and generous participation
      • Therese Djärv, Jonas Willmer – for serendipitous questions
      • Emil Boström, Niclas Lewisson, Lesli Liljegren, Johanna Berg, Lina Holmberg, Patrik Nilsson – for recording what is most likely the internet’s only song on ventricular paced rhythms
      • A patient that permitted us to write a case report​[10]​ and spread the knowledge about how to identify ACS in ventricular paced rhythms
      • Swedish Emergency Talks
        • References
        1. Tabas J, Rodriguez R, Seligman H, Goldschlager N. Electrocardiographic criteria for detecting acute myocardial infarction in patients with left bundle branch block: a meta-analysis. Ann Emerg Med. 2008 Oct 1;52(4):329-336.e1. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18342992
        2. Herweg B, Marcus M, Barold S. Diagnosis of myocardial infarction and ischemia in the setting of bundle branch block and cardiac pacing. Herzschrittmacherther Elektrophysiol. 2016 Sep 1;27(3):307–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27402134
        3. Freitas P, Santos M, Faria M, Rodrigues G, Vale N, Teles R, et al. ECG evaluation in patients with pacemaker and suspected acute coronary syndrome: Which score should we apply? J Electrocardiol. 2016 Sep 1;49(5):744–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27430208
        4. Sgarbossa E, Pinski S, Gates K, Wagner G. Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. GUSTO-I investigators. Am J Cardiol. 1996 Feb 15;77(5):423–4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8602576
        5. Bertel N, Witassek F, Puhan M, Erne P, Rickli H, Naegeli B, et al. Management and outcome of patients with acute myocardial infarction presenting with pacemaker rhythm. Int J Cardiol. 2017 Mar 1;230:604–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28040280
        6. Macfarlane P, Browne D, Devine B, Clark E, Miller E, Seyal J, et al. Modification of ACC/ESC criteria for acute myocardial infarction. J Electrocardiol. 2004 Jan 1;37 Suppl:98–103. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15534817
        7. Maloy K, Bhat R, Davis J, Reed K, Morrissey R. Sgarbossa Criteria are Highly Specific for Acute Myocardial Infarction with Pacemakers. West J Emerg Med. 2010 Sep 1;11(4):354–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21079708
        8. Jothieswaran A, Body R. BET 2: Diagnosing acute myocardial infarction in the presence of ventricular pacing: can Sgarbossa criteria help? Emerg Med J. 2016 Sep 1;33(9):672–3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27539980
        9. Meyers H, Limkakeng A, Jaffa E, Patel A, Theiling B, Rezaie S, et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. Am Heart J. 2015 Dec 1;170(6):1255–64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26678648
        10. 10.Ilicki J, Bruchfeld S, Kolsrud B, Böhm F, Djärv T. Sgarbossa criteria used to identify cardiac ischemia in patient with ventricular paced rhythm. J Electrocardiol. 2018 Jan 1;51(5):830–2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30177322
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