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Cardiology

Chest Pain With Exercise-Induced Left Bundle-Branch Block—Is There a Connection?

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1 Credit CME

JAMA Internal Medicine

Published Online: August 28, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Lei Wang, MD¹;

Yi-Wei Lu, BD¹;

Yun-Tao Zhao, MD, PhD¹

Author Affiliations

¹Department of Cardiology, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing 100049, China

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A patient in their early 60s presented to the cardiology clinic with a 2-week history of chest pain during exertion. The chest pain consistently presented during physical activity, with characteristics indicative of typical angina. The patient was a nonsmoker with no family history of premature coronary artery disease. The baseline 12-lead electrocardiogram (ECG) showed no substantial abnormalities.

A stress ECG was performed during a treadmill test using the Bruce protocol. The patient developed a left bundle-branch block (LBBB) in stage 2 at a heart rate of 107 beats per minute and experienced chest pain, identical to the previous anginal pain (Figure, A). The treadmill test was immediately terminated, with LBBB resolution following exercise cessation and angina relief occurring seconds later (Figure, B).

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A patient in their early 60s presented to the cardiology clinic with a 2-week history of chest pain during exertion. The chest pain consistently presented during physical activity, with characteristics indicative of typical angina. The patient was a nonsmoker with no family history of premature coronary artery disease. The baseline 12-lead electrocardiogram (ECG) showed no substantial abnormalities.

A stress ECG was performed during a treadmill test using the Bruce protocol. The patient developed a left bundle-branch block (LBBB) in stage 2 at a heart rate of 107 beats per minute and experienced chest pain, identical to the previous anginal pain (Figure, A). The treadmill test was immediately terminated, with LBBB resolution following exercise cessation and angina relief occurring seconds later (Figure, B).

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Article Information

Corresponding Author: Yun-Tao Zhao, MD, PhD, Department of Cardiology, Aerospace Center Hospital, 15 Yuquan Rd, Haidian District, Beijing 100049, China (raas@hsc.pku.edu.cn).

Published Online: August 28, 2023. doi:10.1001/jamainternmed.2023.2264

Conflict of Interest Disclosures: None reported.

References

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Virtanen KS , Heikkilä J , Kala R , Siltanen P . Chest pain and rate-dependent left bundle-branch block in patients with normal coronary arteriograms. Chest. 1982;81(3):326-331. doi:10.1378/chest.81.3.326 PubMed Google Scholar Crossref

Suryanarayana PG , Frankel DS , Marchlinski FE , Schaller RD . Painful left bundle-branch block [corrected] syndrome treated successfully with permanent His bundle pacing. HeartRhythm Case Rep. 2018;4(10):439-443. doi:10.1016/j.hrcr.2018.08.005 PubMed Google Scholar Crossref

Tomcsányi J , Somlói M , Wellens H . Narrow QRS complexes within left bundle-branche block in a patient with chest pain. J Electrocardiol. 2020;62:36-38. doi:10.1016/j.jelectrocard.2020.07.019 PubMed Google Scholar Crossref

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.