Chest Pain and a Wide QRS Tachycardia Mazen M. Kawji, MDa, and D. Luke Glancy, MDb,* A 50-year-old man presented to the emergency department with chest pain and his initial electrocardiogram showed sinus tachycardia at a rate of 139 beats/min and left bundle branch block (Figure 1). Because of persistent chest pain and ST-segment elevation of 0.7 mV in lead V2, he underwent coronary arteriography, which demonstrated subtotal occlusion of the left anterior descending coronary artery and highgrade narrowing of its diagonal branch and of the left circumflex and right coronary arteries. A left ventriculogram revealed an ejection fraction of 15%. Urgent multivessel coronary artery bypass grafting was then performed. The electrocardiographic diagnosis of myocardial infarction in patients with right bundle branch block, which deforms the terminal portion of the QRS complex, usually is only minimally more difficult than in patients without a conduction defect. In contrast, left bundle branch block, which deforms the initial portion of the QRS, makes the diagnosis of myocardial infarction considerably more difficult. Seventy years ago, the preeminent electrocardiographer Wilson et al1 wrote, “In the presence of left bundle branch block it is seldom possible to make a diagnosis of myocardial infarction on the basis of electrocardiographic findings alone.” Patients with acute myocardial infarction and left bundle branch block have a higher mortality rate than infarct patients
with normal conduction, regardless of whether the left bundle branch block preceded the infarct or resulted from it.2,3 Prompt diagnosis of the infarct and reperfusion improve prognosis and are essential. Although the diagnosis of old myocardial infarction in the presence of left bundle branch block is nearly as difficult now as in Wilson’s day, we have made progress with acute myocardial infarction. Analysis of patients in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries-1 trial who had left bundle branch block and acute chest pain has yielded 3 electrocardiographic criteria with independent value in the diagnosis of infarction.4 In order of decreasing predictive accuracy, these were ST-segment elevation 0.1 mV and concordant with the QRS complex; ST-segment depression 0.1 mV in lead V1, V2, or V3; and ST-segment elevation 0.5 mV and discordant with the QRS complex (Figure 1). Comparison of the electrocardiogram with previous tracings and serial electrocardiographic changes have also been found to be useful in diagnosing acute myocardial infarction in patients with left bundle branch block.5 A variety of imaging techniques and cardiac markers may improve diagnostic accuracy6 but may also cost valuable time. The history has always been vital as it was in Wilson’s time. In our patient, the history was essential in making a prompt diagnosis and facilitating early revascularization.
Figure 1. Electrocardiogram recorded in the emergency department. See text for explication.
a
Heartland Cardiovascular Center, Joliet, Illinois and bLSU Health Sciences Center, New Orleans. Manuscript received April 13, 2015; revised manuscript received and accepted April 14, 2015. See page 487 for disclosure information. *Corresponding author: Tel: (985) 796-1550; fax: (504) 568-2127. E-mail address: [email protected] (D.L. Glancy). Am J Cardiol 2015;116:487e488 0002-9149/15/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2015.04.039
Disclosures The authors have no conflicts of interest to disclose. 1. Wilson FN, Rosenbaum FF, Johnston FD, Barker PS. The electrocardiographic diagnosis of myocardial infarction complicated by bundle branch block. Arch Inst Cardiol Mex 1945;14:201e212. www.ajconline.org
488
The American Journal of Cardiology (www.ajconline.org)
2. Lie KI, Wellens HJJ, Schuilenburg RM. Bundle branch block and acute myocardial infarction. In: Wellens HJJ, Lie KI, Janse MJ, eds. The Conduction System of the Heart. Philadelphia: Lee & Febiger, 1976: 662e672. 3. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1,000 patients. Lancet 1994;343: 311e322. 4. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, Califf RM, Wagner GS; for the GUSTO-1 (Global Utilization
of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. N Engl J Med 1996;334:481e487. 5. Wackers FJT, Lie KI, David G, Koster RM, Wellens HJJ. Assessment of the value of electrocardiographic signs for myocardial infarction in left bundle branch block. In: Wellens HJJ, Kulbertus HE, eds. What’s New in Electrocardiography. The Hague, The Netherlands: Martinus Nijhoff, 1981:37e57. 6. Sgarbossa EB. Value of the ECG in suspected myocardial infarction with left bundle branch block. J Electrocardiol 2000;33(suppl):87e92.
with normal conduction, regardless of whether the left bundle branch block preceded the infarct or resulted from it.2,3 Prompt diagnosis of the infarct and reperfusion improve prognosis and are essential. Although the diagnosis of old myocardial infarction in the presence of left bundle branch block is nearly as difficult now as in Wilson’s day, we have made progress with acute myocardial infarction. Analysis of patients in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries-1 trial who had left bundle branch block and acute chest pain has yielded 3 electrocardiographic criteria with independent value in the diagnosis of infarction.4 In order of decreasing predictive accuracy, these were ST-segment elevation 0.1 mV and concordant with the QRS complex; ST-segment depression 0.1 mV in lead V1, V2, or V3; and ST-segment elevation 0.5 mV and discordant with the QRS complex (Figure 1). Comparison of the electrocardiogram with previous tracings and serial electrocardiographic changes have also been found to be useful in diagnosing acute myocardial infarction in patients with left bundle branch block.5 A variety of imaging techniques and cardiac markers may improve diagnostic accuracy6 but may also cost valuable time. The history has always been vital as it was in Wilson’s time. In our patient, the history was essential in making a prompt diagnosis and facilitating early revascularization.
Figure 1. Electrocardiogram recorded in the emergency department. See text for explication.
a
Heartland Cardiovascular Center, Joliet, Illinois and bLSU Health Sciences Center, New Orleans. Manuscript received April 13, 2015; revised manuscript received and accepted April 14, 2015. See page 487 for disclosure information. *Corresponding author: Tel: (985) 796-1550; fax: (504) 568-2127. E-mail address: [email protected] (D.L. Glancy). Am J Cardiol 2015;116:487e488 0002-9149/15/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2015.04.039
Disclosures The authors have no conflicts of interest to disclose. 1. Wilson FN, Rosenbaum FF, Johnston FD, Barker PS. The electrocardiographic diagnosis of myocardial infarction complicated by bundle branch block. Arch Inst Cardiol Mex 1945;14:201e212. www.ajconline.org
488
The American Journal of Cardiology (www.ajconline.org)
2. Lie KI, Wellens HJJ, Schuilenburg RM. Bundle branch block and acute myocardial infarction. In: Wellens HJJ, Lie KI, Janse MJ, eds. The Conduction System of the Heart. Philadelphia: Lee & Febiger, 1976: 662e672. 3. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1,000 patients. Lancet 1994;343: 311e322. 4. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, Califf RM, Wagner GS; for the GUSTO-1 (Global Utilization
of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. N Engl J Med 1996;334:481e487. 5. Wackers FJT, Lie KI, David G, Koster RM, Wellens HJJ. Assessment of the value of electrocardiographic signs for myocardial infarction in left bundle branch block. In: Wellens HJJ, Kulbertus HE, eds. What’s New in Electrocardiography. The Hague, The Netherlands: Martinus Nijhoff, 1981:37e57. 6. Sgarbossa EB. Value of the ECG in suspected myocardial infarction with left bundle branch block. J Electrocardiol 2000;33(suppl):87e92.
