809700 ACC European Heart Journal: Acute Cardiovascular CareNeumann et al.

Original scientific paper

European Heart Journal: Acute Cardiovascular Care

Right bundle branch block in 2019, Vol. 8(2) 161­–166

© The European Society of Cardiology 2018
Article reuse guidelines:
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https://doi.org/10.1177/2048872618809700
DOI: 10.1177/2048872618809700
myocardial infarction journals.sagepub.com/home/acc

Johannes Tobias Neumann1,2, Nils Arne Sörensen1,

Nicole Rübsamen1, Francisco Ojeda1, Sarina Schäfer1,
Till Keller3, Stefan Blankenberg1,2, Peter Clemmensen1 and
Dirk Westermann1,2

Abstract
Aims: The new European Society of Cardiology guideline for ST-segment elevation myocardial infarction recommends
that left and right bundle branch block should be considered equal for recommending urgent angiography in patients with
suspected myocardial infarction. We aimed to evaluate this novel recommendation in two prospective studies of patients
with suspected myocardial infarction.
Methods and results: We included 4067 patients presenting to the emergency department with suspected myocardial
infarction. All patients had an ECG recorded immediately upon admission. Patients were classified as having right bundle
branch block (RBBB), left bundle branch block (LBBB), bifascicular block (BFB) or no bundle branch block. All patients
were followed for up to two years to assess mortality. In the overall population 125 (3.1%) patients had RBBB, 281
(6.9%) LBBB and 60 (1.5%) BFB. The final diagnosis of myocardial infarction was adjudicated in 20.8% (RBBB), 28.5%
(LBBB), 23.3% (BFB) and 21.6% (no complete block) of patients. The mortality rate after one year was 10.7% (RBBB), 7%
(LBBB), 17.5% (BFB) and 3.2% (no complete block). The adjusted hazard ratios were 1.29 (95% confidence interval (CI)
0.71–2.34; P=0.40) for RBBB, 1.71 (95% CI 1.17–2.50; P=0.006) for LBBB and 2.27 (95% CI 1.28–4.05; P=0.005) for BFB.
Conclusion: Our results support the new European Society of Cardiology ST-segment elevation myocardial infarction
guideline describing RBBB as a high risk for mortality in patients with suspected myocardial infarction. However, the data
challenge the concept of RBBB as a trigger of acute angiography because the likelihood of myocardial infarction in a chest
pain unit setting is equally frequent in patients without bundle branch block.

Keywords
Acute coronary syndrome, acute myocardial infarction, right bundle branch block, coronary artery disease, diagnosis,
prognosis

Date received: 24 April 2018; accepted: 1 June 2018; Final Disposition Set: 8 October 2018

Introduction
The accurate diagnosis of myocardial infarction (MI) is
challenging, especially when the interpretation of the ECG
is complicated by the presence of confounders such as bun-
1UniversityHeart Center Hamburg, Germany
2GermanCenter for Cardiovascular Research (DZHK), Partner Site
Hamburg/Kiel/Lübeck, Germany
3Kerckhoff Herzforschungsinstitut, University Giessen, Germany

dle branch block.1 Earlier guidelines recommended that

Corresponding author:
urgent angiography should be recommended in patients
Johannes Tobias Neumann, Department of General and Interventional
with a left bundle branch block (LBBB) when MI is sus- Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246
pected.2 The recent 2017 European Society of Cardiology Hamburg, Germany.
(ESC) guideline for patients with ST-segment elevation Email: j.neumann@uke.de
162 European Heart Journal: Acute Cardiovascular Care 8(2)
myocardial infarction (STEMI) now considers LBBB and
right bundle branch block (RBBB) equal in this setting,
with both triggering urgent coronary angiography.3 These
recommendations are based on retrospective analyses from
patients presenting with acute MI.4 Therefore, it is unclear
whether RBBB is associated with a higher risk of having an
MI in a population presenting to an emergency department
(ED). We aimed to evaluate this new recommendation in
two large and prospective studies of patients presenting
with symptoms suggestive of MI investigating differences
in MI incidence and outcome.
Methods
Study populations
For these present analyses, we used pooled data from two
prospective studies including patients presenting with sus-
pected MI to the ED. The stenoCardia and the Biomarkers in
Acute Cardiac Care (BACC) studies have been described
before in detail and are registered online on www.clinicaltri
als.gov (BACC: NCT02355457; stenoCardia: NCT03
227159).5–7 Briefly, the BACC study is an ongoing prospec-
tive study, including patients at the ED and chest pain unit of
the University Hospital Hamburg-Eppendorf. The stenoCar-
dia study included patients presenting with acute chest pain
in three German EDs (Mainz, Koblenz, Hamburg) between
2007 and 2008. All patients were at least 18 years old, pro-
vided written informed consent and had sufficient knowl-
edge of the German language. Patients with haemodynamic
instability were not included. A total of 4067 patients (2265
BACC and 1802 stenoCardia) were available for the analy-
ses. Both studies were approved by the local ethics commit-
tee and complied with the Declaration of Helsinki.
Study-specific measures
All patients with suspected MI were treated according to
the current ESC guidelines, including ECG, monitoring
and serial measurement of high-sensitivity troponin T at
admission and after three hours. The ECG was recorded
immediately upon admission, according to current guide-
lines.2 The ECG was interpreted acutely by the ED physi-
cian and re-interpreted by a research physician during the
adjudication process. Patients were classified as having
RBBB, LBBB, bifascicular block (BFB; RBBB in combi-
nation with left-anterior hemiblock) or no complete bundle
branch block. The clinical parameters and cardiovascular
risk factors were documented by research staff: hyperten-
sion and hyperlipoproteinemia were defined by prior docu-
mentation of a medical doctor or intake of antihypertensive
or lipid-lowering drugs. Diabetes was assessed by intake of
antidiabetic drugs or insulin. Smoking was characterised as
never having smoked, formerly having smoked when hav-
ing stopped at least six weeks prior to admission and cur-
rently smoking. The diagnosis of atrial fibrillation was
based on the admission ECG or on prior diagnosis by a
physician. The history of a coronary artery disease (CAD)
or MI was assessed by questionnaire and prior medical
records. The SYNTAX and the Gensini score were col-
lected from individual interpretation of the coronary angi-
ography by trained physicians.
Adjudication of final diagnosis
The final diagnosis was blindly adjudicated by two physi-
cians and was based on the third universal definition of MI.1
It was based on all available clinical and imaging results,
ECG and laboratory testing (including high-sensitivity tro-
ponin T). In patients with a difficult ECG interpretation (e.g.
bundle branch block) the presence of concordant ST-segment
elevation (e.g. in leads with positive QRS deflections) were
used as indicators for ischaemia. The diagnosis of MI was
adjudicated when evidence of myocardial necrosis and a
clinical setting of myocardial ischaemia were present.
Myocardial necrosis was defined by a high-sensitivity tro-
ponin T concentration above the 99th percentile in combina-
tion with a significant change within three hours.8 Patients
with STEMI and non-STEMI were distinguished. In cases of
disagreement, a third physician reviewed the case.
Follow-up
After the index presentation all patients were followed to
assess all-cause mortality. Patients were contacted by phone/
mail, by contacting the general practitioner or review of the
medical records. In cases without follow-up information, the
local register of death was contacted and all cases of death
were assessed. In all patients who died during the follow-up
the exact cause of death was assessed and adjudicated (car-
diovascular death vs. non-cardiovascular death).
Statistical analyses
Continuous variables were described as quartiles; categori-
cal variables as absolute numbers and percentages. The
Wilcoxon rank sum (for continuous variables) or the χ² (for
categorical variables) test were employed for between-
group comparisons. Survival curves stratified by type of
block were produced using the Kaplan–Meier method.
Survival curve differences were tested with the log rank
test. Hazard ratios (HRs; adjusted for age, sex, hyperten-
sion, hyperlipoproteinemia, smoker status and history of
CAD) were estimated using Cox regression.
Results
In the overall study population 846 of 4067 (20.8%) patients
were adjudicated as having acute MI. In the ECG analyses
RBBB was observed in 125 (3.1%), LBBB in 281 (6.9%)
and BFB in 60 (1.5%) of all patients, while 3601 patients
had no complete bundle branch block (Table 1). Patients
Neumann et al. 163

Table 1.  Characteristics of the overall study population according to type of bundle branch block.

RBBB (N=125) LBBB (N=281) BFB (N=60) No complete P value

block (N=3601)
Age (years) 73.0 (66.0, 78.0) 72.0 (64.0, 78.0) 77.0 (72.0, 82.0) 62.0 (51.0, 73.0) <0.001
Men (%) 100 (80.0) 195 (69.4) 46 (76.7) 2310 (64.1) <0.001
Hypertension (%) 105 (84.0) 245 (87.5) 51 (85.0) 2439 (67.8) <0.001
Hyperlipoproteinemia (%) 72 (57.6) 183 (65.1) 27 (45.0) 1850 (51.4) <0.001
Current smoker (%) 27 (21.8) 43 (15.4) 8 (13.6) 877 (24.5) <0.001
Former smoker (%) 43 (35.2) 88 (31.7) 19 (32.2) 942 (26.5) 0.037
History of MI (%) 39 (31.2) 90 (32.6) 16 (26.7) 610 (17.1) <0.001
History of CAD (%) 68 (55.3) 160 (57.8) 31 (51.7) 1133 (31.8) <0.001
Atrial fibrillation (%) 34 (27.6) 86 (31.3) 24 (40.0) 656 (18.4) <0.001
Heart failure (%) 22 (17.7) 82 (30.0) 18 (30.5) 231 (6.6) <0.001
During admission
Final diagnosis of MI (%) 23 (18.4) 76 (27.0) 13 (21.7) 734 (20.4) 0.064
STEMI (%) 6 (4.8) 11 (3.9) 1 (1.7) 219 (6.1) 0.27
Non-STEMI (%) 17 (13.6) 65 (23.1) 12 (20.0) 515 (14.3) 0.0011
eGFR (mL/min for 1.73 m²) 73.3 (57.3, 87.9) 68.0 (51.2, 84.5) 59.3 (47.6, 71.8) 81.9 (64.9, 94.5) <0.001
GRACE score (points) 115.0 (98.7, 135.3) 123.5 (102.0, 144.6) 132.0 (114.8, 156.0) 91.0 (68.0, 114.0) <0.001
Hs-TnI after 0 hours (ng/L) 9.3 (5.0, 44.4) 20.1 (8.8, 65.4) 11.6 (6.5, 31.9) 6.2 (2.9, 22.4) <0.001
Hs-TnI after 3 hours (ng/L) 10.9 (5.3, 50.1) 23.4 (9.3, 102.2) 15.6 (8.5, 47.2) 6.9 (3.2, 37.6) <0.001
Angiography (%) 46 (36.8) 129 (45.9) 19 (31.7) 1283 (35.6) 0.0066
SYNTAX score 8.5 (0.9, 23.5) 8.0 (0, 21.5) 13.0 (0, 25.5) 7.0 (0, 16.0) 0.76
Gensini score 36.8 (6.3, 50.5) 19.3 (8.4, 59.0) 13.2 (4.0, 54.0) 20.0 (5.0, 47.0) 0.68
PCI (%) 23 (18.4) 60 (21.4) 5 (8.3) 737 (20.5) 0.097

MI: myocardial infarction; CAD: coronary artery disease; eGFR: estimated glomerular filtration rate; PCI: percutaneous coronary intervention;
RBBB: right bundle branch block; LBBB: left bundle branch block; BFB: bifascicular block; STEMI: ST-segment elevation myocardial infarction; hs-TnI:
high-sensitivity troponin I (measured using the Abbott architect system).

with a bundle branch block were older and had a higher
cardiovascular risk profile compared to patients without
bundle branch block. The median GRACE score of patients
with RBBB was 115.0 (25th percentile 98.7, 75th percen-
tile 135.3), while it was significantly lower in patients with-
out complete bundle branch block (91.0 (68.0, 114.0)).
Importantly, the GRACE score was similar in patients with
LBBB (123.5 (102.0, 144.6)); 36.8% of all patients with
RBBB underwent angiography, which was similar to
patients without complete bundle branch block (35.6%).
The median SYNTAX score was similar in all groups (8.5
RBBB, 7.0 without complete bundle branch block), but the
Gensini score was highest in RBBB patients (36.8 RBBB,
20.0 without complete bundle branch block).
Among all patients with RBBB, 23 (18.4%) were diag-
nosed as having MI. While this rate was numerically higher
for patients with LBBB (n=76, 27.0%), it was similar to
that observed in patients without signs of complete bundle
branch block (n=734, 20.4%; Figure 1). Overall, more
patients were diagnosed with non-STEMI compared to
STEMI. Among those patients diagnosed with MI, indi-
viduals with bundle branch block presented more fre-
quently with a history of CAD or heart failure, while the
admission rates for angiography and revascularisation were
similar, when compared to patients without bundle branch
block, exceeding that for LBBB (Table 2).
The median follow-up time was 731 days. The mortality
rate after one year was 10.2% for patients with RBBB,
7.8% for LBBB, 13.7% for BFB and 3.4% for patients
without complete bundle branch block (Figure 2). These
event rates were higher for patients with MI (RBBB 19.2%,
LBBB 14.9%, BFB 30.8%, no complete bundle branch
block 6.5%). Most patients died from a non-cardiovascular
cause (124 out of 216, 57.4%). The rate of non-cardiovas-
cular causes varied according to the bundle branch block
group (RBBB 66.7%, LBBB 26.5%, BFB 46.2%, no com-
plete bundle branch block 64.3%). Unadjusted HRs for all-
cause mortality were 2.31 (95% confidence interval (CI)
1.29–4.16; P=0.005) in patients with RBBB, 2.84 (95% CI
1.96–4.12; P<0.001) in patients with LBBB and 5.44 (95%
CI 3.09–9.57; P<0.001) in patients with BFB (Table 3).
After adjustment the HRs were reduced to 1.29 (95% CI
0.71–2.34; P=0.40) in patients with RBBB, 1.71 (95% CI
1.17–2.50; P=0.006) in patients with LBBB and 2.27 (95%
CI 1.28–4.05; P=0.005) in patients with BFB.
Discussion
In our present analyses we report a relatively low rate of
RBBB in two large prospective studies of patients with sus-
pected MI. Patients having a RBBB were equally likely to
have a final diagnosis of MI and to receive revascularisation
164 European Heart Journal: Acute Cardiovascular Care 8(2)

Figure 1.  Central illustration providing an overview on the main study findings including the prevalence of adjudicated myocardial
infarction (MI) diagnosis according to the type of bundle branch block, the relative risk for MI diagnosis (normalised to 1.00 for
patients without bundle branch block) and the mortality after one year.
RBBB: right bundle branch block; LBBB: left bundle branch block; BFB: bifascicular block; MI: myocardial infarction.

Table 2.  Characteristics of patients diagnosed with MI according to type of bundle branch block.

RBBB (N=23) LBBB (N=76) BFB (N=13) No complete block P value

(N=734)
Age (years) 72.0 (64.8, 78.7) 71.0 (63.4, 79.0) 75.0 (67.0, 80.7) 66.0 (56.0, 75.0) <0.001
Men (%) 21 (91.3) 59 (77.6) 11 (84.6) 520 (70.8) 0.074
Hypertension (%) 20 (87.0) 63 (82.9) 13 (100) 544 (74.1) 0.025
Hyperlipoproteinemia (%) 14 (60.9) 50 (65.8) 7 (53.8) 414 (56.4) 0.44
Current smoker (%) 7 (31.8) 17 (22.4) 2 (15.4) 241 (33.1) 0.16
Former smoker (%) 12 (54.5) 26 (34.2) 7 (53.8) 189 (26.2) 0.0026
History of MI (%) 8 (34.8) 23 (30.7) 4 (30.8) 134 (18.4) 0.012
History of CAD (%) 12 (52.2) 42 (56.0) 9 (69.2) 240 (33.0) <0.001
Atrial fibrillation (%) 3 (13.0) 17 (22.4) 3 (23.1) 130 (17.9) 0.65
Heart failure (%) 4 (17.4) 27 (38.0) 5 (38.5) 58 (8.0) <0.001
During admission
eGFR (mL/min for 1.73 m²) 65.3 (58.1, 74.6) 63.8 (49.3, 77.2) 61.0 (47.7, 68.5) 74.9 (56.8, 90.2) <0.001
GRACE score (points) 121.0 (101.8, 135.5) 128.0 (111.0, 146.1) 140.0 (107.3, 152.7) 104.0 (80.0, 127.0) <0.001
Hs-TnI after 0 hours (ng/L) 473.4 (90.3, 5898.4) 199.2 (26.8, 1314.1) 49.8 (13.9, 490.8) 212.7 (30.5, 1907.8) 0.27
Hs-TnI after 3 hours (ng/L) 712.1 (280.8, 2531.8) 928.0 (157.2, 4236.1) 664.0 (84.9, 4324.5) 1257.7 (217.9, 7227.5) 0.3
Angiography (%) 20 (87.0) 60 (78.9) 9 (69.2) 644 (87.7) 0.039
PCI (%) 15 (65.2) 38 (50.0) 4 (30.8) 500 (68.1) <0.001

MI: myocardial infarction; CAD: coronary artery disease; eGFR: estimated glomerular filtration rate; PCI: percutaneous coronary intervention;
RBBB: right bundle branch block; LBBB: left bundle branch block; BFB: bifascicular block; hs-TnI: high-sensitivity troponin I (measured using the
Abbott architect system).
Neumann et al. 165

Figure 2.  Kaplan–Meier curve for all-cause mortality in (a) the overall population and (b) patients diagnosed with myocardial
infarction according to the type of bundle branch block.
RBBB: right bundle branch block; LBBB: left bundle branch block; BFB: bifascicular block.

Table 3.  Unadjusted and adjusted hazard ratios for all-cause mortality.

Unadjusted Adjusted

  HR (95% CI) P value HR (95% CI) P value

RBBB vs. no complete block 2.31 (1.29, 4.16) 0.0051 1.29 (0.71, 2.34) 0.40
LBBB vs. no complete block 2.84 (1.96, 4.12) <0.001 1.71 (1.17, 2.50) 0.0055
BFB vs. no complete block 5.44 (3.09, 9.57) <0.001 2.27 (1.28, 4.05) 0.0053

Adjustment for age, sex, hypertension, hyperlipoproteinemia, smoker status and history of coronary artery disease.
RBBB: right bundle branch block; LBBB: left bundle branch block; BFB: bifascicular block; HR: hazard ratio; CI: confidence interval.

as those without bundle branch block. In contrast, patients
with LBBB had a higher rate of MI diagnoses. Nevertheless,
patients with RBBB represent a high-risk population with a
high mortality rate.
The cardiovascular outcome of MI patients has con-
stantly improved in the past years due to invasive proce-
dures and optimised medical treatment.9 Partly, this
reduction of mortality is related to urgent revascularisation
performed in patients with MI. This diagnostic strategy is
mostly triggered by changes in ECG, such as ST-segment
elevation or LBBB, both initiating urgent coronary angiog-
raphy. The 2017 ESC STEMI guidelines do recommend
that urgent angiography should not only be considered in
patients with LBBB, but also with RBBB.3 This makes
RBBB highly important when triaging patients in the ED.
The ESC recommendation is based on a sole publication by
Widimsky et al., which reported an association of RBBB
and coronary artery occlusion in a large register of patients
with MI.4 Nevertheless, there is currently a lack of impor-
tant data: the incidence of MI in patients with suspected MI
having a RBBB compared to LBBB is so far unknown.
This gap of knowledge is addressed in our present analyses.
It is important to understand whether RBBB should trigger
distinct diagnostic and treatment pathways.
Our results have several significant clinical implica-
tions: (a) the rate of RBBB among patients with suspected
MI is low; (b) the final diagnosis of MI in patients with
RBBB is equally likely when compared to patients without
bundle branch block; (c) the presence of RBBB is associ-
ated with adverse outcomes, but this effect disappears after
adjustment for confounders.
The detection of RBBB in the general population has
recently been reported in a large cohort including more than
18,000 individuals with 0.9% having a RBBB.10 In that
166 European Heart Journal: Acute Cardiovascular Care 8(2)
study, RBBB was associated with worse cardiovascular
outcomes, even after adjustment for confounding factors.
Importantly, the strongest effect was detected for age and
male sex. These findings might reflect more extensive cor-
onary disease and/or myocardial structural changes leading
to conduction abnormalities having an impact on outcomes.
Interestingly, the rate of RBBB in patients with suspected
MI is still under discussion. We show that the overall inci-
dence in two large and prospective studies is relatively low,
with 3.1% of all patients presenting to the ED. Nevertheless,
it is higher compared to the general population.
Importantly, the presence of RBBB did not change the
likelihood of having MI in patients presenting to the ED
after adjudicated diagnosis in our study. In fact, it was
numerically similar to patients without any bundle branch
block. This was different in patients with LBBB, which
had a higher incidence of MI compared to RBBB.
Therefore, our data do not support an urgent coronary
angiography in patients with RBBB and suspected MI in
the absence of ST-segment elevation, hence questioning
the diagnostic criteria of RBBB alone as a ST-segment
elevation equivalent. This is an important clinical finding
in a field plagued by limited data, because unwarranted
coronary angiographies triggered by RBBB might be
harmful, especially when performed urgently. Nevertheless,
we documented a higher risk of overall mortality in
patients with RBBB in our present study. Given the above
findings, RBBB is not a sign for acute ischaemia but for
long-term cardiac alterations leading to this distinct con-
duction abnormality. Coherently, after adjusting for con-
founders, our data show no significant influence of RBBB
for mortality. This is different for LBBB or BFB, where
outcome was independently predicted by the distinct con-
duction abnormality.
Our study has several strengths, but also limitations.
First, we report the results of prospective studies includ-
ing patients with suspected MI. Second, follow-up infor-
mation was available for nearly the entire study
population, and third, the final diagnosis of each patient
is based on an adjudication process instead of registry
data. However, the absolute rate of recorded RBBB is
relatively low. Furthermore, no information on the pre-
existence of ECG abnormalities was available, but this
reflects clinical routine in the ED triaging patients with
suspected MI rather than an ECG core laboratory inter-
pretation of the standard ECG.
In conclusion, our results support the new ESC
STEMI guideline describing RBBB as a high-risk fea-
ture in patients with suspected MI, however, challenge
the concept of RBBB as a criterion of acute angiography
because the likelihood of identifying a culprit lesion
is rare and equally frequent in patients without ECG
confounders.
Conflict of interest
Dr. Neumann has received honoraria from Siemens and Abbott
Diagnostics. Dr Blankenberg has received honoraria from Abbott
Diagnostics, Siemens, Thermo Fisher and Roche Diagnostics and
is a consultant for Thermo Fisher. Dr Westermann reports per-
sonal fees from Bayer, Boehringer-Ingelheim, Berlin Chemie,
Astra Zeneca, Biotronik and Novartis. The other authors have no
conflicting interests to declare.
Funding
The BACC study was supported by an unrestricted grant by
Abbott Diagnostics. Dr Neumann was supported by a grant from
the German Heart Foundation/German Foundation of Heart
Research and the Else Kröner Fresenius Stiftung.
Trial registration
www.clinicaltrials.gov NCT02355457 (BACC) and NCT03
227159 (stenoCardia)
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