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Carvalho TD, Freitas OGAD, Chalela WA, Hossri CAC, Milani M, Buglia S, Precoma DB, Falcão AMGM, Mastrocola LE, Castro I, Albuquerque PFD, Coutinho RQ, Brito FSD, Alves JDC, Serra SM, Santos MAD, Colombo CSSDS, Stein R, Herdy AH, Silveira ADD, Castro CLBD, Silva MMFD, Meneghello RS, Ritt LEF, Malafaia FL, Marinucci LFB, Pena JLB, Almeida AEMD, Vieira MLC, Stier Júnior AL. Brazilian Guideline for Exercise Test in the Adult Population - 2024. Arq Bras Cardiol 2024; 121:e20240110. [PMID: 38896581 DOI: 10.36660/abc.20240110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Affiliation(s)
- Tales de Carvalho
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
- Universidade do Estado de Santa Catarina, Florianópolis, SC - Brasil
| | | | - William Azem Chalela
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Mauricio Milani
- Universidade de Brasília (UnB), Brasília, DF, Brasil
- Hasselt University, Hasselt - Bélgica
- Jessa Ziekenhuis, Hasselt - Bélgica
| | - Susimeire Buglia
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | - Andréa Maria Gomes Marinho Falcão
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Iran Castro
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | | | | | | | | | - Salvador Manoel Serra
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brasil
| | - Mauro Augusto Dos Santos
- Instituto Nacional de Cardiologia do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
- Linkcare Saúde, Rio de Janeiro, RJ - Brasil
| | | | - Ricardo Stein
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | - Artur Haddad Herdy
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
| | - Anderson Donelli da Silveira
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
| | - Claudia Lucia Barros de Castro
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- CLINIMEX - Clínica de Medicina de Exercício, Rio de Janeiro, RJ - Brasil
| | | | | | - Luiz Eduardo Fonteles Ritt
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Instituto D'Or de Pesquisa e Ensino, Salvador, BA - Brasil
- Hospital Cárdio Pulmonar, Salvador, BA - Brasil
| | - Felipe Lopes Malafaia
- Hospital Samaritano Paulista, São Paulo, SP - Brasil
- UnitedHealth Group Brasil, São Paulo, SP - Brasil
| | - Leonardo Filipe Benedeti Marinucci
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felício Rocho, Belo Horizonte, MG - Brasil
| | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Arnaldo Laffitte Stier Júnior
- Universidade Federal do Paraná (UFPR), Curitiba, PR - Brasil
- Secretaria Municipal de Saúde Curitiba, Curitiba, PR - Brasil
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2
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Barakat AF, Amuthan R, Hariri E, Chana R, Gupta N, Ibrahim J, Bashir ZS, Hu B, Sezer A, Thoma F, Soman P, Mulukutla S, Barzilai B, Ellis SG, Jaber W, Rothberg MB. A Validated Model to Identify Patients With Low Likelihood of High-Risk Coronary Artery Disease Anatomy. Am J Cardiol 2022; 167:27-34. [PMID: 35031112 DOI: 10.1016/j.amjcard.2021.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
In stable coronary artery disease (CAD), revascularization improves outcomes only for patients with high-risk coronary anatomy (HRCA). We sought to derive and validate a prediction model, incorporating clinical and exercise stress test characteristics, to identify patients with HRCA. We conducted a retrospective analysis of patients undergoing exercise stress testing at Cleveland Clinic (2005 to 2014), followed by invasive coronary angiography within 3 months. We excluded patients with acute coronary syndrome, known CAD or ejection fraction <50%. HRCA was defined as left main, 3-vessel, or 2-vessel disease involving the proximal left anterior descending artery. Clinical and stress test predictors of HRCA were identified in a multivariable logistic regression model, internally validated with 1,000-fold bootstrapping. The model was then externally validated at the University of Pittsburgh Medical Center (2017 to 2019). The model was derived from 2,758 patients with complete data. HRCA was identified in 418 patients (15.2%) in the derivation cohort. The model consisted of 10 variables: age, male gender, hypertension, hypercholesterolemia, diabetes mellitus, family history of premature CAD, high-density lipoprotein, chest pain, exercise time, and Duke Treadmill Score. Bias-corrected c-statistic was 0.79 (95% confidence interval 0.77 to 0.81) with excellent calibration. In all, 762 patients (27.6%) had a predicted probability and observed prevalence of HRCA <5%. In the validation cohort, the model had a c-statistic of 0.79 (95% confidence interval 0.74 to 0.85) and 210 patients had an observed prevalence of HRCA <5% (40%). In conclusion, an externally validated prediction model, based on clinical characteristics and exercise stress test variables, can identify stable patients with CAD who have HRCA.
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Affiliation(s)
- Amr F Barakat
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ram Amuthan
- Cardiovascular Division, Department of Medicine, State University of New York, University at Buffalo, Buffalo, New York
| | - Essa Hariri
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rajdeep Chana
- Department of Cardiovascular Medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Niyati Gupta
- Department of Medicine, NYC Health+ Hospitals, New York, New York
| | - Joseph Ibrahim
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zubair S Bashir
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmet Sezer
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Prem Soman
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Benico Barzilai
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stephen G Ellis
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Wael Jaber
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael B Rothberg
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio.
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3
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Scolari FL, Silveira AD, Menegazzo WR, Mendes APC, Pimentel M, Clausell N, Goldraich LA. Expanding benefits from cardiac resynchronization therapy to exercise-induced left bundle branch block in advanced heart failure. ESC Heart Fail 2020; 7:329-333. [PMID: 31923352 PMCID: PMC7083438 DOI: 10.1002/ehf2.12580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/20/2019] [Accepted: 11/11/2019] [Indexed: 01/09/2023] Open
Abstract
Indications of cardiac resynchronization therapy (CRT) do not include exercise‐induced left bundle branch block, but functional impairment could be improved with CRT in such cases. A 57‐year‐old woman with idiopathic dilated cardiomyopathy (ejection fraction 23%) presented with New York Heart Association Class IV and recurrent hospitalizations. During heart transplant evaluation, a new onset of intermittent left bundle branch block was observed on the cardiopulmonary exercise test. CRT was implanted, and 97% resynchronization rate was achieved. In 12 month follow‐up, both clinical and prognostic exercise parameters improved. In patients with heart failure with reduced ejection fraction and no left bundle branch block at rest, exercise test can uncover electromechanical dyssynchrony that may benefit from CRT.
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Affiliation(s)
- Fernando L Scolari
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rua Ramiro Barcelos, 2350, room 2060, Porto Alegre, RS, 90035-903, Brazil
| | - Anderson D Silveira
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rua Ramiro Barcelos, 2350, room 2060, Porto Alegre, RS, 90035-903, Brazil.,Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Willian R Menegazzo
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rua Ramiro Barcelos, 2350, room 2060, Porto Alegre, RS, 90035-903, Brazil
| | - Ana Paula Chedid Mendes
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rua Ramiro Barcelos, 2350, room 2060, Porto Alegre, RS, 90035-903, Brazil
| | - Maurício Pimentel
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rua Ramiro Barcelos, 2350, room 2060, Porto Alegre, RS, 90035-903, Brazil.,Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Nadine Clausell
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rua Ramiro Barcelos, 2350, room 2060, Porto Alegre, RS, 90035-903, Brazil.,Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Livia A Goldraich
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rua Ramiro Barcelos, 2350, room 2060, Porto Alegre, RS, 90035-903, Brazil
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4
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Oladunjoye OO, Oladunjoye AO, Oladiran O, Callans DJ, Schaller RD, Licata A. Persistent Exertional Chest Pain in a Marathon Runner: Exercise-induced, Painful, Left Bundle Branch Block Syndrome Treated With His-Bundle Pacing. Mayo Clin Proc Innov Qual Outcomes 2019; 3:226-230. [PMID: 31193904 PMCID: PMC6543455 DOI: 10.1016/j.mayocpiqo.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
A 49-year-old woman presented with exercise-induced chest discomfort during long-distance running that was occasionally present during rest. Significant coronary artery disease was excluded and a diagnosis of “painful left bundle branch block (LBBB) syndrome” was made after correlation of LBBB aberrancy with symptoms during Holter monitoring. The patient underwent confirmatory testing consisting of rapid atrial pacing below and above 130 beats per minute, the rate cut-off for LBBB manifestation. His bundle pacing implantation was performed resulting in both non-selective and selective morphologies depending on output, both of which manifested with a painless narrow QRS regardless of rate. She was rendered completely pain free during long-distance running and remains so 6-months later. Her pain at rest, now thought to be due to severe anxiety secondary to her painful LBBB, has also subsided. Exercise-induced, painful LBBB is a rare phenomenon that manifests as chest discomfort when LBBB is present. This disease is frequently misdiagnosed as coronary angina, has limited medical treatment options, and can be disabling. HBP is an attractive treatment for this syndrome in an effort to avoid electromechanical dyssynchrony, the presumed mechanism of discomfort. This case report adds to the growing literature of painful LBBB syndrome and its effective treatment with HBP, with the added caveat that it can present with persistent symptoms at rest, in the setting of enhanced anxiety. HBP should be considered early on in the treatment of such patients.
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Affiliation(s)
| | | | | | - David J Callans
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Anthony Licata
- Cardiovascular Division, Department of Medicine, Tower Health Medical Group, Reading Hospital, Reading, PA
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5
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Prystowsky EN, Padanilam BJ. Cardiac resynchronization therapy reverses severe dyspnea associated with acceleration-dependent left bundle branch block in a patient with structurally normal heart. J Cardiovasc Electrophysiol 2019; 30:517-519. [PMID: 30614115 DOI: 10.1111/jce.13840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 11/29/2022]
Abstract
A 55-year-old woman presented with severe dyspnea during acceleration-dependent left bundle branch block (LBBB). Metoprolol initially ameliorated symptoms by preventing the heart rate at which LBBB occurred. Over time LBBB presented at slower heart rates and the patient developed recurrent dyspnea during an activity that correlated with the development of LBBB on event monitors and exercise stress testing. A biventricular pacemaker was implanted, and the patient's symptoms remain resolved after a follow-up of over 4 years. More research is needed to define the use of cardiac resynchronization therapy in patients with normal heart function.
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Affiliation(s)
- Eric N Prystowsky
- St Vincent Medical Group, St Vincent Hospital, Indianapolis, Indiana
| | - Benzy J Padanilam
- St Vincent Medical Group, St Vincent Hospital, Indianapolis, Indiana
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6
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Muniyappa A, Padmanabhan A, Goldschlager N. A Wide Complex Tachycardia in a Woman During Exercise: Did She Tread Into Dangerous Territory? JAMA Intern Med 2019; 179:101-103. [PMID: 30419135 DOI: 10.1001/jamainternmed.2018.6207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anoop Muniyappa
- Department of Medicine, University of California, San Francisco
| | | | - Nora Goldschlager
- Department of Medicine, University of California, San Francisco.,Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
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7
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Gomez M, Lorente Castro B, Jané P, García-Zoghby L, Martínez-Lorca A, Pérez J. Exercise induced left bundle branch block in isotopic exercise test. Findings and prognostic value. Rev Esp Med Nucl Imagen Mol 2018. [DOI: 10.1016/j.remnie.2018.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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8
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Farkas AN, Marcott M, Yanta JH, Pizon AF. Bicarbonate refractory QRS prolongation and left bundle‐branch block following escitalopram and lamotrigine overdose: A case report and literature review of toxic left bundle‐branch block. J Clin Pharm Ther 2018; 43:717-722. [DOI: 10.1111/jcpt.12698] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/28/2018] [Indexed: 12/11/2022]
Affiliation(s)
- A. N. Farkas
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of Pittsburgh School of Medicine Pittsburgh PA USA
| | - M. Marcott
- University of Pittsburgh School of Medicine Pittsburgh PA USA
| | - J. H. Yanta
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of Pittsburgh School of Medicine Pittsburgh PA USA
| | - A. F. Pizon
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of Pittsburgh School of Medicine Pittsburgh PA USA
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9
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Gomez MV, Lorente Castro BC, Jané P, García-Zoghby L, Martínez-Lorca A, Pérez JA. Exercise induced left bundle branch block in isotopic exercise test. Findings and prognostic value. Rev Esp Med Nucl Imagen Mol 2018; 37:273-276. [PMID: 29680771 DOI: 10.1016/j.remn.2018.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/16/2018] [Accepted: 02/21/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Exercise-induced left bundle branch block (EI-LBBB) is a rare circumstance of unknown significance. The purpose of this paper is to describe the scintigraphic features and the prognostic value of this finding. MATERIAL AND METHODS We reviewed the features of 1,885 patients who had visited our department to undergo GATED-SPECT ergometry to diagnose ischaemic heart disease. Seven patients showed EI-LBBB throughout the exercise testing. Coronary angiography was performed in 4 of them. Patients were followed-up over an average period of time of 30±8 months. The onset of major cardiovascular events was recorded during the follow-up period. RESULTS The prevalence of EI-LBBB was 0.37%. Six out of 7 patients were women. Myocardial function and perfusion were normal in 3 patients. Three patients had fixed perfusion defects and one patient had a reversible defect. Two out of the 4 patients showing perfusion defects presented a moderate-severe decrease of the left ventricular ejection fraction. None of the 4 patients with perfusion defects were found to have coronary disease on coronary angiography. CONCLUSIONS The prevalence of EI-LBBB among the patients that came to undergo GATED-SPECT ergometry was very low. The finding was more frequent in women. In our series, 2 patients presented non-ischaemic structural heart disease, but no patient was diagnosed with coronary artery disease. In our patients the presence of EI-LBBB did not relate to a greater risk of experiencing a major cardiovascular event.
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Affiliation(s)
- M V Gomez
- Medicina Nuclear, Hospital Ramón y Cajal, Madrid, España.
| | | | - P Jané
- Hospital Universitario Ramón y Cajal, Madrid, España
| | | | | | - J A Pérez
- Hospital Universitario Ramón y Cajal, Madrid, España
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10
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Farag A, Tsai J, Deeb S, Putman-Garcia D, Wasnick JD, Conlay LA. Rate-Dependent Left Bundle Branch Block in an Ambulatory Surgery Patient: A Case Report. ACTA ACUST UNITED AC 2017; 8:81-85. [PMID: 28045723 DOI: 10.1213/xaa.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 52-year-old woman, ASA II (American Society of Anesthesia classification II) scheduled for cholecystectomy in an ambulatory center, exhibited a wide-complex tachycardia with ectopy on the monitor after induction with propofol and succinylcholine. Blood pressure remained stable; amiodarone was administered for presumed ventricular tachycardia. A 12-lead electrocardiogram (ECG) showed a new left bundle branch block (LBBB) at 98 beats per minute (bpm), which resolved when the heart rate slowed. Surgery was postponed, and both the LBBB and ectopy recurred frequently during the next 24 hours in the intensive care unit, particularly at heart rates >90 bpm. Troponins were normal, and the patient was diagnosed with a rate-dependent LBBB and cleared for surgery.
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Affiliation(s)
- Ashraf Farag
- *Department of Anesthesiology, Texas Tech School of Medicine, Lubbock, Texas; and †Department of Surgery, Texas Tech School of Medicine and Swat Surgical Associates, Lubbock, Texas
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11
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Bazoukis G, Tsimos K, Korantzopoulos P. Episodic Left Bundle Branch Block-A Comprehensive Review of the Literature. Ann Noninvasive Electrocardiol 2016; 21:117-25. [PMID: 27296905 DOI: 10.1111/anec.12361] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/10/2016] [Accepted: 01/19/2016] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- George Bazoukis
- Department of Internal Medicine, General Hospital of Athens "Elpis,", Athens, Greece
| | - Konstantinos Tsimos
- First Department of Cardiology, University of Ioannina, Medical School, Ioannina, Greece
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12
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Czuriga D, Lim PO. Cardiac Resynchronization Therapy Relieves Intractable Angina Due to Exercise-Induced Left Bundle Branch Block Without Left Ventricular Systolic Dysfunction: A Detailed Case Study. J Cardiovasc Electrophysiol 2016; 27:609-12. [PMID: 27170054 DOI: 10.1111/jce.12911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/22/2015] [Accepted: 12/30/2015] [Indexed: 11/30/2022]
Abstract
Exercise-induced left bundle branch block is rare and can be demonstrated with exercise testing. When the heart rate reaches a certain threshold, the QRS widens into left bundle branch block. This paper describes a patient with exercise-induced left bundle branch block related angina and dyspnea, who responded to cardiac resynchronization therapy. We documented the potential benefits of cardiac resynchronization therapy with a left ventricular rapid pacing study prior to its implantation. Although exercise-induced left bundle branch block is not a current indication for cardiac resynchronization therapy in patients such as ours, it could be considered when conventional drug therapy fails.
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Affiliation(s)
- Daniel Czuriga
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, London, UK.,Department of Cardiology, University of Debrecen Medical Center, Debrecen, Hungary
| | - Pitt O Lim
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, London, UK
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13
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Singh H, Patel CD, Mishra S, Bhargava B. Stress-Rest Thallium-201 Myocardial Perfusion SPECT Pattern in Patients with Exercise Induced Left Bundle Branch Block. Nucl Med Mol Imaging 2014; 48:251-4. [PMID: 25177388 DOI: 10.1007/s13139-014-0267-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 02/04/2014] [Accepted: 02/05/2014] [Indexed: 11/25/2022] Open
Affiliation(s)
- Harmandeep Singh
- Department of Nuclear Medicine, All India Institute of Medical Sciences, B-54, South Extension Part-1, New Delhi, 110049 India
| | - Chetan D Patel
- Department of Nuclear Medicine, All India Institute of Medical Sciences, B-54, South Extension Part-1, New Delhi, 110049 India
| | - Sundeep Mishra
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Bhargava
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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14
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Exercise induced left bundle branch block treated with cardiac rehabilitation: a case report and a review of the literature. Case Rep Vasc Med 2014; 2014:204805. [PMID: 24716091 PMCID: PMC3971859 DOI: 10.1155/2014/204805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 12/23/2013] [Indexed: 01/09/2023] Open
Abstract
Exercise induced bundle branch block is a rare observation in exercise testing, accounting for 0.5 percent of exercise tests. The best treatment of this condition and its association with coronary disease remain unclear. We describe a case associated with normal coronary arteries which was successfully treated with exercise training. While this treatment has been used previously, our case has a longer followup than previously reported and demonstrates that the treatment is not durable in the absence of continued exercise.
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15
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Said SAM, Bultje-Peters M, Nijhuis RLG. Exercise-induced left bundle branch block: an infrequent phenomenon: Report of two cases. World J Cardiol 2013; 5:359-363. [PMID: 24109500 PMCID: PMC3783989 DOI: 10.4330/wjc.v5.i9.359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/19/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
Exercise-induced left bundle branch block (EI-LBBB) is infrequent phenomenon. We present two patients with angina pectoris who developed EI-LBBB during exercise tolerance test. The first patient with typical angina pectoris had significant obstructive coronary artery disease (CAD) requiring percutaneous coronary intervention of multiple lesions including placement of drug eluting stents. The second patient had atypical chest pain without signs of CAD at all. EI-LBBB occurred at a heart rate of 80 bpm and 141 bpm in the first and second patient, respectively. EI-LBBB remained visible through the test till the recovery period in the first patient at a heart rate of 83 bpm and disappeared at 96 bpm in the second patient. Both patients with this infrequent phenomenon are discussed and the literature is reviewed.
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16
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Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, Coke LA, Fleg JL, Forman DE, Gerber TC, Gulati M, Madan K, Rhodes J, Thompson PD, Williams MA. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation 2013; 128:873-934. [PMID: 23877260 DOI: 10.1161/cir.0b013e31829b5b44] [Citation(s) in RCA: 1230] [Impact Index Per Article: 111.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Biffi A, Delise P, Zeppilli P, Giada F, Pelliccia A, Penco M, Casasco M, Colonna P, D’Andrea A, D’Andrea L, Gazale G, Inama G, Spataro A, Villella A, Marino P, Pirelli S, Romano V, Cristiano A, Bettini R, Thiene G, Furlanello F, Corrado D. Italian Cardiological Guidelines for Sports Eligibility in Athletes with Heart Disease. J Cardiovasc Med (Hagerstown) 2013; 14:500-15. [DOI: 10.2459/jcm.0b013e32835fcb8a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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A misleading resting ECG in a patient with left bundle branch block. JAAPA 2011; 24:32, 34-5. [DOI: 10.1097/01720610-201101000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Stein R, Nguyen P, Abella J, Olson H, Myers J, Froelicher V. Prevalence and prognostic significance of exercise-induced right bundle branch block. Am J Cardiol 2010; 105:677-80. [PMID: 20185016 DOI: 10.1016/j.amjcard.2009.10.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 10/25/2009] [Accepted: 10/25/2009] [Indexed: 11/25/2022]
Abstract
Exercise-induced (EI) right bundle branch block (RBBB) is an infrequent electrocardiographic phenomenon, and controversy exists regarding its association with cardiovascular disease. We compared the prevalence and prognostic significance of RBBB, abnormal ST depression, and normal electrocardiographic findings in response to exercise testing in 9,623 consecutive veterans who underwent exercise testing from 1987 to 2007. EI RBBB, EI ST depression, and a normal exercise electrocardiographic response occurred in 0.24%, 15.2%, and 71.9% veterans, respectively. After appropriate exclusions, of the 8,047 patients analyzed, 6 patients in the EI RBBB subgroup died. Of these 6 deaths, 3 were cardiovascular deaths during the 9 years of follow-up. The annual death rate was 7.3% (1.4% cardiac deaths), 2.6% (1.2% cardiac deaths), and 1.8% (0.6% cardiac death) among those with EI RBBB, EI ST depression, and a normal ST response, respectively (p <0.0001). The patients with EI RBBB were significantly older, more overweight, and had a greater prevalence of coronary artery disease, heart failure, and hypertension compared to the 2 other subgroups. Patients with EI RBBB had an age-adjusted Cox proportional hazard ratio of 1.13 (p = 0.75, 95% confidence interval 0.51 to 2.5) for all-cause mortality and 1.57 (p = 0.43, 95% confidence interval 0.51 to 4.8) for cardiovascular mortality, respectively. In conclusion, EI RBBB is a rare occurrence during routine clinical exercise testing that appears to be benign.
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20
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Ciaroni S, Urban P. Painful left bundle branch block detected during dobutamine stress echocardiography. J Am Soc Echocardiogr 2002; 15:1405-8. [PMID: 12415237 DOI: 10.1067/mje.2002.124005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We report on the observation, in a 50-year-old woman undergoing dobutamine stress echocardiography, of the simultaneous onset of complete left bundle branch block and anginal chest pain, unaccompanied by any abnormality of left ventricular segmental contraction or wall thickening. Further etiologic investigations, in particular for coronary artery disease, proved negative. This observation is discussed in the context of a literature review.
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Affiliation(s)
- Stefano Ciaroni
- Service de cardiologie, Hôpital de la Tour, Meyrin-Geneva, Switzerland
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21
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Candell Riera J, Oller Martínez G, Vega J, Gordillo E, Ferreira I, Peña C, Castell J, Aguadé S, Soler Soler J. [Exercise-induced left bundle-branch block in patients with coronary artery disease versus patients with normal coronary arteries]. Rev Esp Cardiol 2002. [PMID: 12015926 DOI: 10.1016/s0300-8932(02)76638-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION AND OBJECTIVES Exercise-induced left bundle-branch block does not always denote the presence of underlying coronary artery disease. The aim of this study was to analyze the clinical characteristics and evolution of patients with rate-dependent left bundle-branch block. PATIENTS AND METHOD 9,318 consecutive exercise stress studies were reviewed. The clinical characteristics and evolution (mean follow-up: 6.9 years) of 20 patients with exercise-induced left bundle-branch block in which coronary angiography had been performed were analyzed. RESULTS Eight out of 20 patients had normal coronary arteries (group A) and 12 had coronary artery disease (group B). Peak O2 consumption, peak myocardial O2 consumption, and heart rate when block appeared (132 20 vs. 95.4 23 beats/min; p = 0.002) were significantly higher in group A. Seven of the 8 patients with normal coronary arteries had chest pain coinciding with the first beat of left bundle-branch block. There were no deaths during follow-up in group A, but permanent left bundle-branch block appeared in 5 patients of this group who experienced disappearance of exercise-related pain. There were 3 deaths in group B and 2 patients had acute myocardial infarction during follow-up. One patient in each group developed atrioventricular block and required pacemaker implantation. CONCLUSIONS In contrast with patients with left bundle-branch block and coronary artery disease, the prognosis of patients with painful left bundle-branch block and normal coronary arteries is good. However, the development of permanent left bundle-branch block is frequent. Atrioventricular block, although rare, may occur.
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Affiliation(s)
- Jaume Candell Riera
- Servicios de Cardiología y Medicina Nuclear. Hospital Universitari Vall d'Hebron. Barcelona. Spain.
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22
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Candell-Riera J, Gordillo E, Oller-Martínez G, Peña C, Ferreira I, Soler-Soler J. Long-term outcome of painful left bundle branch block. Am J Cardiol 2002; 89:602-4. [PMID: 11867050 DOI: 10.1016/s0002-9149(01)02304-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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23
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Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B, Eckel R, Fleg J, Froelicher VF, Leon AS, Piña IL, Rodney R, Simons-Morton DA, Williams MA, Bazzarre T. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694-740. [PMID: 11581152 DOI: 10.1161/hc3901.095960] [Citation(s) in RCA: 1125] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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24
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Seitelberger R, Wild T, Serbecic N, Schwarzacher S, Ploner M, Lassnigg A, Podesser B. Significance of right bundle branch block in the diagnosis of myocardial ischemia in patients undergoing coronary artery bypass grafting. Eur J Cardiothorac Surg 2000; 18:187-93. [PMID: 10925228 DOI: 10.1016/s1010-7940(00)00424-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Perioperative diagnosis of myocardial ischemia following cardiac surgical procedures remains a challenging problem. Particularly, the role of new conduction disturbances as markers of postoperative ischemia is still questionable. The goal of this study was to elucidate the diagnostic significance of new postoperative right bundle branch block (RBBB) for the detection of perioperative myocardial ischemia in patients undergoing elective coronary artery bypass grafting (CABG). METHODS In 169 consecutive patients, three-channel Holter monitoring and serial assessment of serum enzymes were performed for 48 h, and 12-lead ECG repeated for up to 5 days postoperatively. Postoperative events were classified as either myocardial infarction (MI), transient ischemic events (TIE) or various conduction disturbances. RESULTS Transient (n=9) or permanent (n=4) RBBB occurred in 13 patients (8%); 14 patients (8%) showed signs of perioperative MI and 18 patients (11%) evidence of TIE. Peak activity of creatine-kinase (CK, 561+/-135 vs. 316+/-19, P<0.05) and CK-MB (22.7+/-3.2 vs. 13.4+/-0.8, P<0.01) were higher in patients with RBBB than in patients without perioperative ischemic events. Peak CK-MB levels were significantly higher in patients with MI as compared to those with RBBB (33.4+/-7.6 vs. 22.7+/-3.2, P<0. 05). Patients with TIE had similar perioperative enzyme levels as patients with no events. CONCLUSION It is concluded that the combined assessment of repeated 12-lead ECG, continuous Holter monitoring and enzyme analysis allows a reliable diagnosis of perioperative myocardial ischemia and conduction disturbances. The occurrence of new RBBB following elective CABG is indicative of perioperative myocardial necrosis and thus serves as a valuable tool for the diagnosis of new, perioperative ischemic events.
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Affiliation(s)
- R Seitelberger
- Department of Cardiothoracic Surgery, University of Vienna, AKH Vienna, Währingergürtel 18-20, 1090, Vienna, Austria.
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25
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Affiliation(s)
- G F Fletcher
- Division of Cardiovascular Diseases, Mayo Clinic Jacksonville, USA
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26
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Tyagi SC. Vasculogenesis and angiogenesis: Extracellular matrix remodeling in coronary collateral arteries and the ischemic heart. J Cell Biochem 1997. [DOI: 10.1002/(sici)1097-4644(19970601)65:3<388::aid-jcb8>3.0.co;2-o] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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27
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Yotsukura M, Suzuki J, Tsuda M, Ishikawa K. Transient disappearance of complete right bundle branch block during exercise in a patient with old inferior wall myocardial infarction. J Electrocardiol 1995; 28:323-6. [PMID: 8551175 DOI: 10.1016/s0022-0736(05)80050-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To date, there has been no report of temporary disappearance of right bundle branch block (RBBB) during exercise. A patient with old infero-posterior myocardial infarction is described in whom complete RBBB disappeared transiently during treadmill exercise testing. No chest pain or significant ST-T changes occurred during and after the exercise periods. Any of the following mechanisms could have been involved: (1) the patient's complete RBBB might have been bradycardia-dependent, (2) an exercise-induced increase of sympathetic tone might have produced a temporary improvement of the conduction disturbances, or (3) the exercise might have elicited conduction disturbances in the main left bundle branch, which could have concealed a conduction delay in the main trunk of the right bundle branch.
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Affiliation(s)
- M Yotsukura
- Second Department of Internal Medicine, Kyorin University, School of Medicine, Tokyo, Japan
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Fletcher GF, Balady G, Froelicher VF, Hartley LH, Haskell WL, Pollock ML. Exercise standards. A statement for healthcare professionals from the American Heart Association. Writing Group. Circulation 1995; 91:580-615. [PMID: 7805272 DOI: 10.1161/01.cir.91.2.580] [Citation(s) in RCA: 383] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- G F Fletcher
- Office of Scientific Affairs, American Heart Association, Dallas, TX 75231
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29
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Moran JF, Scurlock B, Henkin R, Scanlon PJ. The clinical significance of exercise-induced bundle branch block. J Electrocardiol 1992; 25:229-35. [PMID: 1645063 DOI: 10.1016/0022-0736(92)90008-n] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Exercise-induced bundle branch block is an uncommon electrocardiographic entity said to be associated with coronary heart disease. Thirty-seven patients were studied to determine if exercise hemodynamics and stress/rest thallium scans could identify those patients with coronary heart disease. Eighteen patients of the study group also had coronary angiography. Group I (n = 17) with normal thallium scans and group II (n = 20) with abnormal thallium scans had significantly different maximal heart rate, maximal blood pressure, and double product in exercise as well as duration of exercise. Clinical evaluation of the patient study group permitted a division of the patients into two subgroups: group A, atypical chest pain or abnormal exercise electrocardiogram (n = 12), and group B, definite or probable angina (n = 25). Group B patients had significantly more abnormal thallium scans (17/25) than group A patients (3/12) (p less than 0.04). When compared to coronary angiography, stress/rest thallium scans had a predictive accuracy of 85% for coronary heart disease. While exercise-induced ST-segment depression and R wave amplitude increases are not specific in exercise-induced bundle branch block, exercise hemodynamics and stress/rest thallium scans can help diagnose patients with coronary heart disease. These test findings added to a clinical evaluation permit a more accurate stratification of the patients and indicate which patients need further study.
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Affiliation(s)
- J F Moran
- Loyola University Medical Center, Maywood, Illinois
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30
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Cantwell JD, Pettus CW. Exercise ECG. PHYSICIAN SPORTSMED 1992; 20:123-124. [PMID: 29287533 DOI: 10.1080/00913847.1992.11947414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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31
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Parker JS, deBoisblanc BP. Case report: intermittent, positive pressure ventilation-dependent right bundle branch block. Am J Med Sci 1991; 302:380-1. [PMID: 1772124 DOI: 10.1097/00000441-199112000-00011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 73-year-old man with severe chronic obstructive pulmonary disease and cor pulmonale developed an intermittent right bundle branch block (RBBB) during mechanical ventilation. The appearance and disappearance of his RBBB was temporally associated with each positive pressure breath. Intermittent RBBB is a previously undescribed complication of positive pressure ventilation.
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Affiliation(s)
- J S Parker
- Department of Medicine, Louisiana State University Medical School, New Orleans 70112
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32
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Fletcher GF, Froelicher VF, Hartley LH, Haskell WL, Pollock ML. Exercise standards. A statement for health professionals from the American Heart Association. Circulation 1990; 82:2286-322. [PMID: 2242557 DOI: 10.1161/01.cir.82.6.2286] [Citation(s) in RCA: 220] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- G F Fletcher
- Office of Scientific Affairs, American Heart Association, Dallas, TX 75231
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