Chest pain associated with rate-related left bundle branch block and cardiac memory mimicking ischemia

Abstract

Background: Intermittent left bundle branch block (LBBB) has been linked to chest pain, and causes cardiac memory electrocardiographic (ECG) changes mimicking ischemia. Purpose: To present a case of chest pain with ECG abnormalities suggestive of ischemia, both likely caused by LBBB. Case: A 33-year-old hypertensive female evaluated for chest pain and LBBB by ECG was treated with lisinopril and metoprolol, and scheduled for stress testing. A 12-lead ECG performed prior to the stress test, due to recurrence of the chest pain the preceding night, showed resolution of the LBBB with a lower heart rate, and T-wave inversions in the precordial leads suggestive of ischemia. She developed chest pains with reappearance of LBBB during stress testing, which prompted cardiac catheterization. This revealed normal coronaries and left ventricular systolic function. The ECG abnormalities were in retrospect likely due to cardiac memory. Her chest pains may have been caused by the intermittent, rate-related LBBB, as control of her heart rate and blood pressure with metoprolol and lisinopril improved her symptoms on follow-up. Conclusion: Intermittent LBBB causes chest pain and electrocardiographic abnormalities suggestive of ischemia in the absence of obstructive coronary disease. Certain clinical and electrocardiographic features may provide clues to a non-ischemic etiology. <Learning objective: In the absence of obstructive coronary disease, rate-related left bundle branch block is associated with chest pain described as local, non-radiating, with palpitations and walk-through phenomenon. It can also cause electrocardiographic (ECG) changes of cardiac memory, which mimic myocardial ischemia, but with T waves that are positive in lead aVL, positive or isoelectric in lead I, and more inverted in the precordial leads compared with lead III. These clinical and ECG features may provide clues to non-coronary etiology of chest pain.>

Chest Pain Resolution with His-bundle Pacing in a Patient with Left Bundle Branch Block–related Nonischemic Left Ventricular Dysfunction

“…1,2 Few cases have been reported to date in the literature, and no specific treatments are available at this time. 3 Case presentations of sudden chest pain with a LBBB appearance and chest pain resolution with the disappearance of LBBB aberrancy have been reported. 4 Theories for this have been introduced, including cardiac mechanical dyssynchrony; clinical and ECG characteristic features have also been proposed in order to provide more guided and appropriate therapies, which have included β-blockers, exercise, and RV or biventricular pacing options.…”

Non-ischemic Painful Intermittent Left Bundle Branch Block With Infra-Hisian Block Treated Successfully With Biventricular Pacemaker: A Case Report and Literature Review

“…Painful ILBBB is an uncommon variant that results in chest pain that appears simultaneously with the development of LBBB and occurs with or without myocardial ischemia. The prevalence of this condition in the general population is still unknown, as it is uncommon and frequently underrecognized owing to coexisting coronary artery disease [ 6 ]. The underlying mechanism of rate-dependent ILBBB and chest pain in patients with normal coronary arteries is not well understood.…”