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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing a long lesion in mid-right coronary artery&#46; There is severe narrowing of the lumen&#44; critical in the distal part of the lesion&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 55-year-old patient with a history of hypertension&#44; hyperlipidemia and a former smoker presented with stable angina pectoris with onset three months earlier&#46; No abnormalities were found on physical examination&#46; The resting electrocardiogram &#40;ECG&#41; and a cardiac echocardiographic examination were normal&#46; Standard Bruce protocol treadmill test was performed&#46; Patient achieved a heart rate of 151 beats per minute &#40;92&#37; of the maximal predicted heart rate&#41;&#46; Maximum workload achieved was 12 metabolic equivalents&#46; There were no arrhythmias and pressure response to exercise was normal&#46; Patient reported mild chest discomfort at maximal effort&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Electrocardiogram recording during the test is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46; It shows dynamic changes during exercise consistent with &#60;2 mm upsloping ST depression in V5 and V4 leads and mildly horizontal ST depression in V6 lead&#46; Upon closer analysis&#44; the QRS axis ranges from normal &#40;65&#176;&#41; to right axis &#40;100&#176; in stage 4&#41; and leads aVL and I become progressively <span class="elsevierStyleBold">negative</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; This pattern is consistent with left posterior fascicular block&#46; All these changes occurred in maximum exercise and rapidly returned to resting values in recovery&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A dobutamine stress echocardiogram was performed&#44; with a clearly positive result&#44; showing development of typical angina&#44; ST elevation in II&#44; III and aVF leads &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; and motion abnormalities in inferior wall &#40;Video 1&#41;&#46; The patient underwent coronary angiography revealing critical stenosis in the middle segment of the right coronary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; which was successfully treated with stent implantation&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The appearance of transient left posterior fascicular block &#40;LPFB&#41; patterns has been related to the development of transient injury in the posteroinferior left ventricular wall owing to right or widespread coronary artery disease &#40;CAD&#41; and chronic posteroinferior damage&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Induced left anterior fascicular block &#40;LAFB&#41; seems to be more specifically associated with significant disease of the left anterior descending coronary artery&#46;<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&#46; Estimated prevalence is less than 0&#46;3&#37; of all treadmill tests&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Bobba et al&#46; reported four patients with transient LPFB during exercise&#46; All of them had significant disease of the proximal right coronary artery and two had significant disease of the left coronary artery&#46;<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&#46; Some authors have hypothesized about ischemia-induced slow conduction in a cluster of fibers within the left bundle&#44; its subdivisions&#44; or even in Purkinje or parietal myocardial fibers&#46;<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&#46; Even with a suboptimal sensitivity in some cases&#44; it is a non-invasive&#44; safe and efficient study of diagnostic and prognostic value&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Due to this&#44; it is very important to have a deep knowledge of its interpretation&#44; in order to gather as much information as possible&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">ST-segment depression is the generally agreed criterion of a positive treadmill test&#44; but other abnormal response patterns have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Exercise-induced transient left fascicular blocks&#44; as the one we presented&#44; are infrequent but also a strong marker of CAD&#46; It is a subtle alteration which&#44; should it go unnoticed&#44; the clinician would miss the likely diagnosis of severe CAD&#46; In an era of sophisticated diagnostic tools&#44; it is interesting to see that the reliable treadmill test still can reveal surprises&#46; Its finding in a patient with chest pain warrants a most comprehensive study with imaging stress tests or coronary angiography&#46;</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&#46;</p></span></span>"
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        "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&#46; Treadmill test revealed exercise-induced left posterior fascicular block&#44; which is an uncommon and easily unnoticed marker of coronary artery disease&#46; A dobutamine stress echocardiogram was performed&#44; with a clearly positive result&#46; Coronary angiography revealed critical stenosis in the right coronary artery&#46;</p></span>"
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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
Autor para correspondência
virginia.ruizpizarro@gmail.com

Corresponding author.
, Julián Palacios-Rubio, Miguel Ángel Cobos-Gil
Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 55-year-old patient with a history of hypertension&#44; hyperlipidemia and a former smoker presented with stable angina pectoris with onset three months earlier&#46; No abnormalities were found on physical examination&#46; The resting electrocardiogram &#40;ECG&#41; and a cardiac echocardiographic examination were normal&#46; Standard Bruce protocol treadmill test was performed&#46; Patient achieved a heart rate of 151 beats per minute &#40;92&#37; of the maximal predicted heart rate&#41;&#46; Maximum workload achieved was 12 metabolic equivalents&#46; There were no arrhythmias and pressure response to exercise was normal&#46; Patient reported mild chest discomfort at maximal effort&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Electrocardiogram recording during the test is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46; It shows dynamic changes during exercise consistent with &#60;2 mm upsloping ST depression in V5 and V4 leads and mildly horizontal ST depression in V6 lead&#46; Upon closer analysis&#44; the QRS axis ranges from normal &#40;65&#176;&#41; to right axis &#40;100&#176; in stage 4&#41; and leads aVL and I become progressively <span class="elsevierStyleBold">negative</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; This pattern is consistent with left posterior fascicular block&#46; All these changes occurred in maximum exercise and rapidly returned to resting values in recovery&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A dobutamine stress echocardiogram was performed&#44; with a clearly positive result&#44; showing development of typical angina&#44; ST elevation in II&#44; III and aVF leads &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; and motion abnormalities in inferior wall &#40;Video 1&#41;&#46; The patient underwent coronary angiography revealing critical stenosis in the middle segment of the right coronary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; which was successfully treated with stent implantation&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The appearance of transient left posterior fascicular block &#40;LPFB&#41; patterns has been related to the development of transient injury in the posteroinferior left ventricular wall owing to right or widespread coronary artery disease &#40;CAD&#41; and chronic posteroinferior damage&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Induced left anterior fascicular block &#40;LAFB&#41; seems to be more specifically associated with significant disease of the left anterior descending coronary artery&#46;<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&#46; Estimated prevalence is less than 0&#46;3&#37; of all treadmill tests&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Bobba et al&#46; reported four patients with transient LPFB during exercise&#46; All of them had significant disease of the proximal right coronary artery and two had significant disease of the left coronary artery&#46;<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&#46; Some authors have hypothesized about ischemia-induced slow conduction in a cluster of fibers within the left bundle&#44; its subdivisions&#44; or even in Purkinje or parietal myocardial fibers&#46;<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&#46; Even with a suboptimal sensitivity in some cases&#44; it is a non-invasive&#44; safe and efficient study of diagnostic and prognostic value&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Due to this&#44; it is very important to have a deep knowledge of its interpretation&#44; in order to gather as much information as possible&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">ST-segment depression is the generally agreed criterion of a positive treadmill test&#44; but other abnormal response patterns have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Exercise-induced transient left fascicular blocks&#44; as the one we presented&#44; are infrequent but also a strong marker of CAD&#46; It is a subtle alteration which&#44; should it go unnoticed&#44; the clinician would miss the likely diagnosis of severe CAD&#46; In an era of sophisticated diagnostic tools&#44; it is interesting to see that the reliable treadmill test still can reveal surprises&#46; Its finding in a patient with chest pain warrants a most comprehensive study with imaging stress tests or coronary angiography&#46;</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&#46;</p></span></span>"
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        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Doente de 55 anos com angina est&#225;vel e com eletrocardiograma e ecocardiograma normais&#46; A prova de esfor&#231;o em tapete rolante revelou bloqueio fascicular anterior esquerdo induzido pelo esfor&#231;o&#44; um marcador relativamente pouco conhecido de doen&#231;a coron&#225;ria&#46; Foi realizado um ecocardiograma de esfor&#231;o com dobutamina que foi claramente positivo&#46; A angiografia coron&#225;ria revelou estenose cr&#237;tica da art&#233;ria coron&#225;ria direita&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Rest and exercise electrocardiogram recording during Bruce protocol treadmill test&#46; From left to right&#58; rest&#44; stage 1&#44; stage 2&#44; stage 3 and stage 4 &#40;maximum effort&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Rest versus maximum effort cardiac axis comparison&#46; Notice the progressive change in I and aVL leads&#44; turning a normal cardiac axis to right&#46; This pattern is compatible with left posterior fascicular block&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram during dobutamine 30 mcg&#47;kg&#47;min&#46; ST-segment elevation in inferior leads &#40;II&#44; III and aVF&#41; and ST depression in I and aVL leads suggesting inferoposterior wall ischemia&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing a long lesion in mid-right coronary artery&#46; There is severe narrowing of the lumen&#44; critical in the distal part of the lesion&#46;</p>"
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                      "titulo" => "Transient hemiblock&#58; an abnormal type of response to the Master two-step test"
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