Diagnosing and Treating Left Bundle Branch Block ECG Finding as An Acute Coronary Syndrome Event in Rural Hospital of East Sumba: A Case Report
Author : T.S.R. Sembiring
Upload Date : 19-04-2018
Background: Acute coronary syndrome (ACS) presenting as left bundle branch block (LBBB) ECG finding is a challenging case because there’s an alteration of its ECG that produces “masking” effect of the ST segment elevation. In order to avoid over-diagnosis of LBBB as an ACS, understanding the widely accepted algorithm of treating LBBB may be the only reliable tool to diagnose and treat LBBB especially in rural area such as East Sumba.
Case Illustration: A 59-year-old male came to ER due to sudden breathlessness. He was unable to lie supine and showing excessive effort of breathing. He was a heavy smoker with history of uncontrolled hypertension. On physical examination, he was very dyspneic and tachycardic. Congestive signs were found consisting of increased jugular venous pressure, bilateral rales of both lungs and pitting edema on feet. Cardiac sound was regular with systolic murmur best heard on apex of cordis and accompanied by S3 gallop. ECG finding showed a classic form of LBBB supported by cardiomegaly and pulmonary edema on CXR. He was diagnosed with acute lung oedema (ALO) and LBBB due to ACS and consequently given loading dose of aspirin and clopidogrel, fondaparinux injection and continuous injection of furosemide.
Discussion: Based on the algorithm proposed by American College of Cardiology, clinicians who find LBBB cases must first judge whether the patient is unstable. Unstable patient must be treated as an ACS. This patient was admitted with ALO. Therefore he was hemodynamically unstable and treated as ACS. Supposedly, the patient had to be referred to the closest PCI centre. Yet, it couldn’t be reached in 120 minutes and streptokinase was unavailable. Thus, the patient could only be treated with antithrombotic and anticoagulant.
Conclusion: An LBBB ECG finding isn’t always a STEMI. Understanding the algorithm of LBBB treatment may aid in giving the best treatment for hemodynamically unstable patients presenting with LBBB ECG finding who are appropriate for ACS treatment.
KEYWORDS : left bundle branch block; acute coronary syndrome; STEMI.