Arterial orthostatic anemia with cardiac pains: Akesson, S.: Acta med. Scandinav. (Suppl.) 196:192, 1947

Abstract

Forty-three patients with left bundle branch block were studied, twentyeight of whom appeared to have “uncomplicated” left bundle branch block, that is, they presented neither a history of myocardial infarction nor symptoms of anginal character associated with effort or rest. In fifteen patients evidence of myocardial infarction was obtained, either by necropsy or by electrocardiographic signs observed in tracings prior to the development of left bundle branch block or after its disappearance, or by a characteristic history suggestive of myocardial infarction in conjunction with confirmatory clinical and laboratory evidence. In nine patients anterior infarction was diagnosed, in five, posterior infarction, and in one, the signs of anterior and posterior infarction were combined.By comparing the tracings of “uncomplicated” left bundle branch block with records presenting evidence of complicating myocardial infarction, certain features were discerned which appeared to be suggestive of myocardial infarction in association with left bundle branch block.Uncomplicated left bundle branch block has some features in common with anterior wall infarction: 1) Q waves in Lead I and/or in leads from the left side of the precordium (very rare); 2) absent R waves (QS deflections) or R waves less than 1 mm. high in leads from the right side of the precordium; 3) marked elevation (up to 7 mm.) of the RS-T junction and high T waves (up to 19 mm.) in leads from the right side of the precordium which display deep S waves or QS deflections; and 4) inverted T waves in Lead I and/or in leads from the left side of the precordium which, in the presence of uncomplicated left bundle branch block, usually display asymmetrical limbs and slightly depressed RS-T junctions.The following features were considered as suggestive of anterior wall infarction in the presence of left bundle branch block. 1.1) Q waves in Lead I and/or in precordial leads from left-side positions, especially when R deflections are present in the precordial leads from the right side.2.2) Elevation of the RS-T junction in Lead I or in the chest leads, when it is either preceded by a prominent R deflection or followed by flat, diphasic (plusminus) or inverted T waves; in precordial leads displaying deep S or QS waves, when the elevation of the RS-T junction measures more than 8 mm. or when it is followed by a T wave whose amplitude is less than twice the distance of the elevated RS-T junction from the level of reference (in the absence of digitalis eflect).3.3) Reciprocal depression of the RS-T junction in Lead III, when it measures more than one-sixth of the amplitude of the predominant QRS deflection in Lead III.4.4) Diphasic (plus-minus) or inverted T waves in those chest leads displaying a deep S or QS deflection.5.5) Inverted T waves with symmetrical limbs and RS-T junctions not depressed in Lead I and/or in chest leads from left-side positions.Posterior wall infarction has some features in common with left bundle branch block: 1) Q waves or QS deflections in Lead III; 2) elevation of the RS-T junction in Leads II and III; 3) depression of the RS-T junction in Lead I and in leads from the left side of the precordium; and 4) inversion of the T wave in Leads II and III.The following features were considered as suggestive of posterior infarction in the presence of left bundle branch block. 1.1) Q waves or QS deflections in Lead III in conjunction with Q waves or W-shaped QRS complexes (or Q wave equivalents) in Lead II.2.2) Elevation of the RS-T junction in Lead III (and II), when it follows an R deflection or when it measures more than one-sixth of the amplitude of the S deflection in the same lead.3.3) Depression of the RS-R junction in Lead I and/or in chest leads from the left positions, when it measures more than one-seventh of the amplitude of the preceding R deflection.4.4) Depression of the RS-T junction in chest leads displaying a prominent S or QS deflection.5.5) Coronary T waves in Leads II and III.6.6) Inversion of the T wave in Leads II and III, when the inverted phase in Lead III measures more than 3 millimeters.Post-mortem examination was obtained for two patients with anterior infarction and two with posterior infarction. The tracings of these patients showed significant Q waves or Q-wave equivalents. The interventricular septum was involved in all. These findings support the assumption of Wilson that infarction of the interventricular septum may be an important factor in the development of significant Q waves when left bundle branch block is present∗.