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Between 1991 and 2013, we evaluated the demographics, presentations, and final diagnosis of patients hospitalized with acute cardiac events and left bundle branch block (LBBB). Of 50 992 patients, 768 (1.5%) had LBBB. Compared with non-LBBB patients, patients with LBBB were mostly older, female, diabetic, and had hypertension and chronic kidney fai...
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... A new or presumably new-onset BBB in an appropriate setting is pathological with management similar to an STelevation myocardial infarction (STEMI). [2] In a recent registry, the prevalence of left BBB (LBBB) was around 2%. [3] Acute coronary syndrome (ACS) associated with a BBB has a higher risk of adverse cardiac events and mortality, especially with right BBB (RBBB). [4,5] The evidence or guidance on the management approach to transient BBB during the perioperative period is lacking. ...
... Left bundle branch block (LBBB) is a pattern seen on the surface ECG, which results when there is alteration of normal electrical activity in the His-Purkinje fibres. 1 Most often, LBBB occurs from chronic conditions that progressively damage the conduction system (eg, coronary artery disease, hypertension, cardiomyopathy) or more acutely from myocardial ischaemia or myocarditis, among others. [2][3][4] Infrequently does it manifest in patients with structurally normal hearts without coronary disease and even less commonly does the LBBB appear intermittently. 5 6 We present the case of a 70-year-old woman with HER2+/ER+ breast cancer on adjuvant trastuzumab therapy who presented with respiratory failure from influenza and was found to have intermittent LBBB with new onset systolic heart failure in the setting of chemotherapy-induced cardiotoxicity. ...
A 70-year-old woman with HER2+/ER+ breast cancer on adjuvant trastuzumab therapy without a history of cardiovascular disease presented with respiratory failure from influenza and was found to have intermittent left bundle branch block (LBBB) with new onset systolic heart failure. Her course was complicated by polymorphic ventricular tachycardia and recurrent chest pain. Significant investigations included a normal cardiac MRI and cardiac catheterisation with unobstructed coronaries. It was determined that the aetiology of her heart failure was trastuzumab-induced cardiotoxicity after comprehensive workup. This case highlights an uncommon presentation of LBBB and the steps taken to diagnose a rare cardiomyopathy.
... 1,4 Left bundle branch block (LBBB) was defined as a QRS duration of >0.120 seconds in the presence of sinus rhythm, dominant S wave or rS in V1, broad monophasic R wave in I, aVL, and V5 to V6 associated with the absence of a Q wave in the same lead. [7][8][9][10] On-admission acute cardiac events included acute heart failure or AMI. The simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria was required to establish a diagnosis of CHF. ...
We conducted a retrospective analysis of 50 974 patients admitted with acute cardiac events with and without right bundle branch block (RBBB) over 23 years. Compared to non-RBBB, patients with RBBB (n = 386; 0.8%) were 3 years older ( P = .001), more likely to present with breathlessness rather than chest pain ( P = .001), and had more diabetes mellitus ( P = .001). Patients with RBBB had significantly higher cardiac enzymes ( P = .001); however, there were no significant differences in the presentation with ST-segment elevation myocardial infarction (24.6% vs 22.2%), non-ST-segment elevation myocardial infarction (23.7% vs 22.4%), and unstable angina (51.7% vs 55.4%). Patients with RBBB were more likely to have congestive heart failure (CHF; 9.6% vs 3.2%, P = .001), cardiogenic shock (10.6% vs 1.7%, P = .001), and ventricular tachyarrhythmias (7.3% vs 2.2%, P = .001). Left ventricular ejection fraction and hospital length of stay were comparable between the groups. All-cause mortality was 5 times greater in patients with RBBB (21% vs 4.2%, P = .001). Right bundle branch block was independent predictor of mortality (adjusted odd ratio 5.14; 95% confidence interval: 3.90-6.70). Subanalysis comparing normal QRS, RBBB, and left BBB showed that RBBB was associated with the worst outcomes except for CHF. Although RBBB presents in only about 1% of patients with cardiac disease, it was found to be an independent predictor of hospital mortality.
... 3 Although it has been proposed that symptomatic patients with new or presumably new left bundle branch block (LBBB) and anginal pain should be treated as STEMI equivalents, in a recent registry the proportion of myocardial infarction was significantly lower among patients with LBBB (21%) compared to those without LBBB (32%). 4 Apart from coronary artery disease (CAD), other causes of LBBB include valve disease, dilated cardiomyopathy, infiltrative cardiomyopathy, hypertensive cardiomyopathy, congenital heart disease, degenerative conduction heart disease (Lenegre and Lev diseases), myocarditis, infective endocarditis, heart trauma/surgery, hyperkalemia, myxedema, and systemic sclerosis. 5 Our review provides a comprehensive overview of transient or intermittent LBBB cases described in the literature and discusses its clinical impact. ...
Episodic (transient/ intermittent) left bundle branch block (LBBB) has been associated with different conditions such as bradycardia, tachycardia, anesthesia, acute pulmonary embolism, changes in intrathoracic pressure, chest trauma, cardiac interventional procedures, mad honey poisoning, and in other clinical settings. Of note, exclusion of an acute coronary syndrome in the setting of episodic LBBB is of great importance. Moreover, episodic LBBB is sometimes symptomatic and may be associated with left ventricular systolic and/or diastolic dysfunction or conduction disturbances leading to syncope. This review article provides a comprehensive overview of the conditions associated with episodic LBBB and discusses the clinical impact of this phenomenon.
Background:
In-hospital cardiac arrest (IHCA) may be preventable, with patients often showing signs of physiological deterioration before an event. Our objective was to develop and validate a simple clinical prediction model to identify the IHCA risk among cardiac arrest (CA) patients hospitalized with acute coronary syndrome (ACS).
Hypothesis:
A predicting model could help to identify the risk of IHCA among patients admitted with ACS.
Methods:
We conducted a case-control study and analyzed 21 337 adult ACS patients, of whom 164 had experienced CA. Vital signs, demographic, and laboratory data were extracted from the electronic health record. Decision tree analysis was applied with 10-fold cross-validation to predict the risk of IHCA.
Results:
The decision tree analysis detected seven explanatory variables, and the variables' importance is as follows: VitalPAC Early Warning Score (ViEWS), fatal arrhythmia, Killip class, cardiac troponin I, blood urea nitrogen, age, and diabetes. The development decision tree model demonstrated a sensitivity of 0.762, a specificity of 0.882, and an area under the receiver operating characteristic curve (AUC) of 0.844 (95% CI, 0.805 to 0.849). A 10-fold cross-validated risk estimate was 0.198, while the optimism-corrected AUC was 0.823 (95% CI, 0.786 to 0.860).
Conclusions:
We have developed and internally validated a good discrimination decision tree model to predict the risk of IHCA. This simple prediction model may provide healthcare workers with a practical bedside tool and could positively impact decision-making with regard to deteriorating patients with ACS.
Background:
Functional tests have limited accuracy for identifying myocardial ischemia in patients with left bundle branch block (LBBB).
Objective:
To assess the diagnostic accuracy of dipyridamole-stress myocardial computed tomography perfusion (CTP) by 320-detector CT in patients with LBBB using invasive quantitative coronary angiography (QCA) (stenosis ≥ 70%) as reference; to investigate the advantage of adding CTP to coronary computed tomography angiography (CTA) and compare the results with those of single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy.
Methods:
Thirty patients with LBBB who had undergone SPECT for the investigation of coronary artery disease were referred for stress tomography. Independent examiners performed per-patient and per-coronary territory assessments. All patients gave written informed consent to participate in the study that was approved by the institution's ethics committee.
Results:
The patients' mean age was 62 ± 10 years. The mean dose of radiation for the tomography protocol was 9.3 ± 4.6 mSv. With regard to CTP, the per-patient values for sensitivity, specificity, positive and negative predictive values, and accuracy were 86%, 81%, 80%, 87%, and 83%, respectively (p = 0.001). The per-territory values were 63%, 86%, 65%, 84%, and 79%, respectively (p < 0.001). In both analyses, the addition of CTP to CTA achieved higher diagnostic accuracy for detecting myocardial ischemia than SPECT (p < 0.001).
Conclusion:
The use of the stress tomography protocol is feasible and has good diagnostic accuracy for assessing myocardial ischemia in patients with LBBB.
