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Masson R, Bakhshi H, Haddad TM. Intermittent left bundle branch block and acute heart failure in trastuzumab-induced cardiotoxicity. BMJ Case Rep 2020; 13:13/7/e236009. [PMID: 32723779 DOI: 10.1136/bcr-2020-236009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
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.
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Affiliation(s)
- Ravi Masson
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Hooman Bakhshi
- Department of Cardiology, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Tariq M Haddad
- Department of Cardiology, Inova Heart and Vascular Institute, Falls Church, Virginia, USA.,Department of Cardiology, Virginia Heart, Falls Church, Virginia, USA
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2
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Alkindi F, El-Menyar A, Rafie I, Arabi A, Al Suwaidi J, Singh R, Albinali H, Gehani AA. Clinical Presentations and Outcomes in Patients Presenting With Acute Cardiac Events and Right Bundle Branch Block. Angiology 2019; 71:256-262. [DOI: 10.1177/0003319719892159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Ayman El-Menyar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Ihsan Rafie
- Cardiology Department, Heart Hospital, Doha, Qatar
| | | | - Jassim Al Suwaidi
- Cardiology Department, Heart Hospital, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
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Li H, Wu TT, Yang DL, Guo YS, Liu PC, Chen Y, Xiao LP. Decision tree model for predicting in-hospital cardiac arrest among patients admitted with acute coronary syndrome. Clin Cardiol 2019; 42:1087-1093. [PMID: 31509271 PMCID: PMC6837031 DOI: 10.1002/clc.23255] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Hong Li
- Department of Nursing, Fujian Provincial Hospital, Fujian, China
| | - Ting Ting Wu
- Department of Nursing, Fujian Health College, Fujian, China
| | - Dong Liang Yang
- Department of General Education Courses, Cangzhou Medical College, Hebei, China
| | - Yang Song Guo
- Department of Cardiovascular Medicine, Fujian Provincial Hospital, Fujian, China
| | - Pei Chang Liu
- Department of Anesthesiology, Union Hospital Affiliated to Fujian Medical University, Fujian, China
| | - Yuan Chen
- Department of Nursing, Xiamen Cardiovascular Disease Hospital, Xiamen, China
| | - Li Ping Xiao
- Department of Nursing, First Hospital of Longyan, Longyan, China
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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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Cabeda EV, Falcão AMG, Soares J, Rochitte CE, Nomura CH, Ávila LFR, Parga JR. Dipyridamole stress myocardial perfusion by computed tomography in patients with left bundle branch block. Arq Bras Cardiol 2015; 105:614-24. [PMID: 26421532 PMCID: PMC4693666 DOI: 10.5935/abc.20150117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/20/2015] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Estêvan Vieira Cabeda
- Departamento de Tomografia e Ressonância Cardiovascular, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Andréa Maria Gomes Falcão
- Departamento de Medicina Nuclear, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Soares
- Departamento de Medicina Nuclear, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Carlos Eduardo Rochitte
- Departamento de Tomografia e Ressonância Cardiovascular, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brazil
| | - César Higa Nomura
- Departamento de Tomografia e Ressonância Cardiovascular, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Francisco Rodrigues Ávila
- Departamento de Tomografia e Ressonância Cardiovascular, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Rodrigues Parga
- Departamento de Tomografia e Ressonância Cardiovascular, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brazil
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Affiliation(s)
- Konstantinos C. Koskinas
- First Cardiology Department, AHEPA Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Antonios Ziakas
- First Cardiology Department, AHEPA Hospital, Aristotle University Medical School, Thessaloniki, Greece
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