Abstract
Background : Patients with acute heart failure and left bundle branch block (LBBB) presenting acute chest pain have many clinical challenges to perform the diagnostic and therapeutic process. Recent recommendations revealed that the patients with LBBB (new or presumably new) should be performed early revascularization. However, several clinical controversies occurred due to scientific gaps between current evidence and recommen- dations. Therefore, the review of other approaches to assess this setting might be required. Objective : This case report aims to describe factors related to early revascularization strategy in patients with long standing heart failure and left bundle branch block. Case : A 46-year-old man with the previous history of dyspnea (long-standing heart failure) was admitted to our hospital with recurrent chest pain and acute heart failure. Electrocardiogram (ECG) showed LBBB suggesting acute myocardial infarction (excessive discordance in the precordial lead). He had normal serial cardiac enzymes with ongoing ischemia symptoms. He had been decided not to perform urgent reperfusion therapy. After five days of hospitalization, he discharged home with medicines. Our case report provided an example of applying the existing algorithm to assess acute chest pain in congestive heart failure, regardless of ST-segment deviation in LBBB. Conclusion : Clinical judgement and the use of objective findings offer the best way to determine the need for early reperfusion in our case.
Highlights
Heart failure is the most common health problem in the emergency department (ED) admissions, either acute or chronic congestive heart failure (CHF)
Clinical judgement and the use of objective findings offer the best way to determine the need for early reperfusion in our case
The primary consideration in these patients is a higher risk for acute myocardial infarction (AMI), congestive heart failure, and sudden death compared to patients without
Summary
Acute coronary syndrome (ACS) should be evaluated while facing congestive heart failure patients. The electrocardiographic (ECG) diagnosis of ACS is often unknown due to altered myocardial depolarization.[2] The primary consideration in these patients is a higher risk for acute myocardial infarction (AMI), congestive heart failure, and sudden death compared to patients without. Studies showed that less than half of patients with acute chest pain (suspected AMI) and LBBB had an occluded culprit artery, and I might have an essential impact on the revascularization.[6] Recognizing the chronicity of LBBB without evaluating previous ECG is impossible due to asymptomatic condition. Our present case demonstrated the alternative strategies in patients with severe heart failure with LBBB and acute chest pain. Understanding the clinical hemodynamic condition, ECG presentation, and imaging or laboratory studies could provide additional insight into this clinical setting
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