Bottom Line

Why It’s Important for Emergency Medicine

  • We’ve been told that you just can’t accurately read cardiac ischemia on an EKG in the setting of a LBBB – even when you apply the Sgarbossa criteria. Its specificity is great (~98%), but with a sensitivity of around 20%, you’re missing a whole lot of acute MI’s.
  • Part of the problem is that LBBBs normally produce an ST-elevation in V1-V4, obscuring your ability to identify anterior MI’s. The original Sgarbossa criteria tries to solve this with its 3rd component: an ST-elevation in excess of 5 mm identifies an acute MI. Well, you can imagine that if the entire EKG suffers from low-voltage, the ST-elevation may not reach 5 mm, and you’d still miss acute MI’s.
  • As with everything in life, proportions should matter more than absolute size! This universal rule applies to the ST-elevations in LBBBs as well. Using a ratio of ST-elevation / S-wave < -0.25 will identify almost twice as many acute MI’s as using an absolute cutoff.

Major Points1

  • 33 Study EKGs versus 129 matched controls
Sens Spec + LR – LR
Modified Rule 91 90 9.0 0.1
Original weighted 52 98 22 0.5
Original unweighted 67 90 6.6 0.4


As you can see, this study is small. And as if the original Sgarbossa wasn’t hard enough to remember, this modified version is not very “user friendly”…

Reviewed by V. Nguyen

MIA 2012 = Most Interesting Articles series of 2012

Smith S, Dodd K, Henry T, Dvorak D, Pearce L. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012;60(6):766-776. [PubMed]
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg San Francisco General. Founder of ALiEM @aliemteam #PostitPearls
Michelle Lin, MD