Case report
Exercise-induced left fascicular block: A forgotten sign of coronary disease
Bloqueio fascicular anterior esquerdo induzido pelo exercício: um sinal esquecido de doença coronária
Virginia Ruiz-Pizarro
, Julián Palacios-Rubio, Miguel Ángel Cobos-Gil
Corresponding author
Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
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There is severe narrowing of the lumen, critical in the distal part of the lesion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 55-year-old patient with a history of hypertension, hyperlipidemia and a former smoker presented with stable angina pectoris with onset three months earlier. No abnormalities were found on physical examination. The resting electrocardiogram (ECG) and a cardiac echocardiographic examination were normal. Standard Bruce protocol treadmill test was performed. Patient achieved a heart rate of 151 beats per minute (92% of the maximal predicted heart rate). Maximum workload achieved was 12 metabolic equivalents. There were no arrhythmias and pressure response to exercise was normal. Patient reported mild chest discomfort at maximal effort.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Electrocardiogram recording during the test is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>. It shows dynamic changes during exercise consistent with <2 mm upsloping ST depression in V5 and V4 leads and mildly horizontal ST depression in V6 lead. Upon closer analysis, the QRS axis ranges from normal (65°) to right axis (100° in stage 4) and leads aVL and I become progressively <span class="elsevierStyleBold">negative</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). This pattern is consistent with left posterior fascicular block. All these changes occurred in maximum exercise and rapidly returned to resting values in recovery.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A dobutamine stress echocardiogram was performed, with a clearly positive result, showing development of typical angina, ST elevation in II, III and aVF leads (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>) and motion abnormalities in inferior wall (Video 1). The patient underwent coronary angiography revealing critical stenosis in the middle segment of the right coronary artery (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>), which was successfully treated with stent implantation.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Exercise-induced left fascicular block is an uncommon and easily unnoticed coronary disease marker.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The appearance of transient left posterior fascicular block (LPFB) patterns has been related to the development of transient injury in the posteroinferior left ventricular wall owing to right or widespread coronary artery disease (CAD) and chronic posteroinferior damage.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Induced left anterior fascicular block (LAFB) seems to be more specifically associated with significant disease of the left anterior descending coronary artery.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There is little literature relating to this phenomenon. Estimated prevalence is less than 0.3% of all treadmill tests.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Bobba et al. reported four patients with transient LPFB during exercise. All of them had significant disease of the proximal right coronary artery and two had significant disease of the left coronary artery.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The mechanism of this alteration is not completely known. Some authors have hypothesized about ischemia-induced slow conduction in a cluster of fibers within the left bundle, its subdivisions, or even in Purkinje or parietal myocardial fibers.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The stress treadmill test is still widely used for chest pain workup and as routine follow-up in cardiac rehabilitation units. Even with a suboptimal sensitivity in some cases, it is a non-invasive, safe and efficient study of diagnostic and prognostic value.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Due to this, it is very important to have a deep knowledge of its interpretation, in order to gather as much information as possible.</p><p id="par0040" class="elsevierStylePara elsevierViewall">ST-segment depression is the generally agreed criterion of a positive treadmill test, but other abnormal response patterns have been described.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Exercise-induced transient left fascicular blocks, as the one we presented, are infrequent but also a strong marker of CAD. It is a subtle alteration which, should it go unnoticed, the clinician would miss the likely diagnosis of severe CAD. In an era of sophisticated diagnostic tools, it is interesting to see that the reliable treadmill test still can reveal surprises. Its finding in a patient with chest pain warrants a most comprehensive study with imaging stress tests or coronary angiography.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1569194" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1413962" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1569195" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1413963" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-04" "fechaAceptado" => "2018-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1413962" "palabras" => array:3 [ 0 => "Treadmill test" 1 => "Left fascicular block" 2 => "Coronary artery disease" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1413963" "palabras" => array:3 [ 0 => "Prova de esforço em tapete rolante" 1 => "Bloqueio fascicular anterior esquerdo" 2 => "Doença coronária" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 55-year-old patient presented with stable angina pectoris with normal physical examination on rest electrocardiogram and cardiac echocardiogram. Treadmill test revealed exercise-induced left posterior fascicular block, which is an uncommon and easily unnoticed marker of coronary artery disease. A dobutamine stress echocardiogram was performed, with a clearly positive result. Coronary angiography revealed critical stenosis in the right coronary artery.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Doente de 55 anos com angina estável e com eletrocardiograma e ecocardiograma normais. A prova de esforço em tapete rolante revelou bloqueio fascicular anterior esquerdo induzido pelo esforço, um marcador relativamente pouco conhecido de doença coronária. Foi realizado um ecocardiograma de esforço com dobutamina que foi claramente positivo. A angiografia coronária revelou estenose crítica da artéria coronária direita.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0055" class="elsevierStylePara elsevierViewall">The following are the supplementary material to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0015" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1974 "Ancho" => 1005 "Tamanyo" => 991496 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Rest and exercise electrocardiogram recording during Bruce protocol treadmill test. From left to right: rest, stage 1, stage 2, stage 3 and stage 4 (maximum effort).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4175 "Ancho" => 2124 "Tamanyo" => 1544766 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Rest versus maximum effort cardiac axis comparison. Notice the progressive change in I and aVL leads, turning a normal cardiac axis to right. This pattern is compatible with left posterior fascicular block.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 571 "Ancho" => 1674 "Tamanyo" => 264557 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram during dobutamine 30 mcg/kg/min. ST-segment elevation in inferior leads (II, III and aVF) and ST depression in I and aVL leads suggesting inferoposterior wall ischemia.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 765 "Ancho" => 755 "Tamanyo" => 77336 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing a long lesion in mid-right coronary artery. There is severe narrowing of the lumen, critical in the distal part of the lesion.</p>" ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 253067 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ischemia-associated intraventricular conduction disturbances during exercise testing as a predictor of proximal left anterior descending coronary artery disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K.J. 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Bricker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Circulation" "fecha" => "2002" "volumen" => "106" "paginaInicial" => "1883" "paginaFinal" => "1892" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000004000000009/v1_202109070616/S2174204921002592/v1_202109070616/en/main.assets" "Apartado" => array:4 [ "identificador" => "9914" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000004000000009/v1_202109070616/S2174204921002592/v1_202109070616/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204921002592?idApp=UINPBA00004E" ]
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