• Heart Rhythm · Jan 2016

    Review Case Reports

    Painful left bundle branch block syndrome: Clinical and electrocardiographic features and further directions for evaluation and treatment.

    • Alexei Shvilkin, Ethan R Ellis, Ernest V Gervino, Anthony D Litvak, Alfred E Buxton, and Mark E Josephson.
    • Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; South Shore Hospital, South Weymouth, Massachusetts. Electronic address: ashvilki@bidmc.harvard.edu.
    • Heart Rhythm. 2016 Jan 1; 13 (1): 226-32.

    BackgroundPainful left bundle branch block (LBBB) is a rarely diagnosed chest pain syndrome caused by intermittent LBBB in the absence of myocardial ischemia. Its prevalence, mechanism, detailed electrocardiographic (ECG) features, and effective treatments are not well described.ObjectivesThe purpose of this study was to characterize clinical and ECG features of patients with painful LBBB syndrome with respect to the LBBB ECG morphology (in particular QRS axis and the precordial S/T wave ratio), clarify diagnostic criteria and possible mechanisms, and provide directions for further evaluation and treatment.MethodsWe analyzed clinical (n = 50) and ECG (n = 15) features of patients with painful LBBB syndrome (4 patients in our practice and 46 cases identified in the literature).ResultsAll 15 ECGs of patients with painful LBBB syndrome had an inferior QRS axis and a very low (<1.8) precordial S/T wave ratio, which was consistent with the "new LBBB" pattern. We report a case of painful LBBB syndrome coexisting with coronary artery disease. Right ventricular apical pacing resolved intractable chest pain in 1 case of painful LBBB.ConclusionPainful LBBB ECG morphology within seconds/minutes of its onset is consistent with the new LBBB pattern with a very low (<1.8) precordial S/T wave ratio and inferior QRS axis. Painful LBBB syndrome can coexist with coronary artery disease, complicating the assessment of chest pain in the setting of LBBB. An electrophysiology study might be considered to investigate whether changing ventricular activation pattern by pacing provides consistent pain control and to select the most effective pacing configuration.Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

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