Large variability in clinical judgement and definitions of left bundle branch block to identify candidates for
A M W van Stipdonk1, S Vanbelle2, I A H Ter Horst3
1Cardiology department, Maastricht University Medical Center, Maastricht, the Netherlands.
Insights
Diagnosing left bundle branch block (LBBB) for cardiac resynchronisation therapy (CRT) is inconsistent. Different definitions and clinical judgment show significant variability, impacting patient selection for CRT.
Area of Science:
- Cardiology
- Medical Diagnostics
- Electrocardiography
Background:
- Left bundle branch block (LBBB) is crucial for predicting cardiac resynchronisation therapy (CRT) outcomes.
- Current LBBB definitions are numerous and their application appears subjective.
- Variability in LBBB diagnosis can affect patient selection for CRT.
Purpose of the Study:
- To assess inter- and intra-observer agreement in LBBB determination using various definitions.
- To evaluate the consistency of clinicians' judgment in identifying LBBB.
- To understand the impact of definition variability on LBBB classification.
Main Methods:
- 100 ECGs from CRT patients were analyzed by four observers using four LBBB definitions (ESC, AHA/ACC/HRS, MADIT, Strauss).
- Four implanting cardiologists provided clinical judgment on the same ECGs.
- Agreement was quantified using proportion of agreement (P) and kappa coefficient (k).
Main Results:
- Intra-observer agreement was moderate (k range: 0.47-0.74), while inter-observer agreement was minimal to weak (k range: 0.19-0.44).
- The probability of classifying LBBB varied widely (0.20-0.76) across definitions.
- Agreement between definitions ranged from good (P=0.95) to weak (P=0.40), with poor correlation to clinical judgment (phi 0.30-0.55).
Conclusions:
- Significant variation exists in LBBB classification due to differing definitions and clinical judgment.
- Substantial intra- and inter-observer variability complicates accurate LBBB diagnosis.
- Inter-definition agreement is inconsistent, and clinical judgment poorly correlates with LBBB definitions.
Background:
Left bundle branch block (LBBB) morphology is associated with improved outcome of cardiac resynchronisation therapy (CRT) and is an important criterion for patient selection. There are, however, multiple definitions for LBBB. Moreover, applying these definitions seems subjective. We investigated the inter- and intraobserver agreement in the determination of LBBB using available definitions, and clinicians' judgement of LBBB.
Methods:
Observers were provided with 12‑lead ECGs of 100 randomly selected CRT patients. Four observers judged the ECGs based on different LBBB-definitions (ESC, AHA/ACC/HRS, MADIT, and Strauss). Additionally, four implanting cardiologists scored the same 100 ECGs based on their clinical judgement. Observer agreement was summarized through the proportion of agreement (P) and kappa coefficient (k).
Results:
Relative intra-observer agreement using different LBBB definitions, and within clinical judgement was moderate (range k 0.47-0.74 and k = 0.76 (0.14), respectively). The inter-observer agreement between observers using LBBB definitions as well as between clinical observers was minimal to weak (range k 0.19-0.44 and k = 0.35 (0.20), respectively). The probability of classifying an ECG as LBBB by available definitions varied considerably (range 0.20-0.76). The agreement between different definitions of LBBB ranged from good (P = 0.95 (0.07)) to weak (P = 0.40 (0.22)). Furthermore, correlation between the different LBBB definitions and clinical judgement was poor (range phi 0.30-0.55).
Conclusion:
Significant variation in the probability of classifying LBBB is present in using different definitions and clinical judgement. Considerable intra- and inter-observer variability adds to this variation. Interdefinition agreement varies significantly and correlation of clinical judgement with LBBB classification by definitions is modest at best.
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