An unusual case of left bundle branch block (60 year old male CC: Shortness of breath)

Here’s a really interesting case submission from David Baumrind.

EMS is called out in a rain storm to evaluate a 60 year old male with a chief complaint of shortness of breath.

The patient was released from the rehab center 8 days prior after having experienced a stroke while having his “carotids done”.

He suffers from persistent left-sided hemiparesis.

For approximately 36 hours prior to contacting 9-1-1 the patient experienced increasing shortness of breath made worse by lying flat or with physical activity (paroxysmal nocturnal dyspnea and new exertional dyspnea).

The patient is found sitting in a living room chair. He is in no acute distress at the time of evaluation.

Skin is slightly “dusky” but warm and dry.

The patient denies chest discomfort. He admits to some nausea but has not vomited. He denies light-headedness and palpitations.

Past medical history: NIDDM, CABG x 4 years ago, myocardial infarction, left bundle branch block, ICD placement

Medications: Numerous but unavailable at the time of evaluation

Vital signs

RR: 22
Pulse: 96 and irregular
BP: 142/82
SpO2: 92 on RA

The cardiac monitor is attached.

A 12-lead ECG is captured.

Here is the computerized interpretive statement.

What do you think is going on with this patient?

Are you concerned about his 12-lead ECG?

You are 15 minutes from the local non-PCI hospital and the STEMI Receiving Center is 45 minutes in the opposite direction.

See also:

63 year old male CC: Chest pain

8 Comments

  • Mark says:

    This patient should probably go to the local hospital for evaluation. He has an old L BBB which makes diagnosis harder. He is a good candidate for PE.

  • Mark P says:

    LBBB with LAD, and consequent deep S wave in V6 (a combination often found in large failing hearts), with frequent RBBB-pattern ventricular ectopic beats (basal LV, inferior origin). I’m not sure what to make of the ST depression in V5 and V6. That would be considered ‘normal’ in a standard LBBB ECG where there is also a negative T wave – i.e. the more standard appearance found in aVL and lead I. But since there is an RS pattern in those leads you could almost consider V5 a V3 equivalent…which would suggest infarction but that has no strong literature to back it up. So DD: heart failure (due to any cause), infarction/ischaemia ➝ heart failure, (PE mentioned above is a good thought).

  • Brandon O says:

    The computer interpretation is good — looks like LBBB with a mess of ectopy (nearly trigeminous), and nearly a 1st degree heart block. The ST depression in V5 (most notable in the PVC) is arguably more severe than would be appropriate for the rule of discordance, but I would not get too excited about it. You could also argue for a hair of depression in I and II, but at some point you’re just looking for trouble.

    Nearest facility for stabilization, serial ECGs. An MI is not impossible but there is no world where I’d recommend calling it based on this 12-lead… I’m much more concerned about his overall cardiac stability and heart failure. PE is a possibility too.

  • Bryan says:

    Is SOB his typical anginal equivalent? What about when he had the old MI? Perhaps the patient has an old EKG given his awareness of his LBBB, does he have an old EKG?

    I would hazard a provisonal dx of left sided heart failure 2nd to AMI most likely. I don’t know if this EKG is diagnostic, but there is a ton of ectopy. Ischemia?

    His SPO2 of 92% and new orthopnea and SOBOE are concerning as well. How is the patient’s renal function?

  • Bryan says:

    oh yeah, transport to local hospital for eval.

  • Christopher says:

    Weird LBBB, monomorphic R in I, slurred S in V6.

    I’m game for heart failure, nothing stands out for a STEMI alert. I’d be on my toes though.

  • could the STE in aVR be problematic in the context of what appears to me to be early global STD? LMCA occlusion?

  • merciful says:

    The wide complexes aren't VPCs at all!! they are aberrantly conducted complexes(right bundle fatigue even in this rate–Ashmann phenomenon; yessss!!!) . so he has LBBB and easily fatigued right bundle: he has conduction problem in both branches.. possibly PM needed; however, as he already has an ICD in place (hopefully a DDD-D, or better to say  CRT-D)  this topic is history forever. On the other hand, we have a pretty well ST depressions in D2-avf- v4-6. although lateral derivations are far from perfect LBBB, he definitely has ST depressions concordant with terminal forces. this is absolutely abnormal. I think he has inferolateral ischemia (not injury-cause there is no ST elevation). I'd probably take him to catheter room after having him cooled down a bit  with heparin, ASA, statins, lasix, and nitrates.. 
    thanks in advance for responses

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