Exercise-induced left bundle branch block: an infrequent phe
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Case :
An 80-year-old male with well treated hypertension and paroxysmal atrial fibrillation was evaluated for chest pain exaggerated by physical stress with a good reaction to sublingual nitroglycerin. On examination his body mass index (BMI) was 29 kg/m2, rest blood pressure was 129/81 mmHg and rest heart rate of 60 bpm. Neither cardiac murmur or signs of congestive heart failure were present. The rest of the examination was normal. Resting electrocardiogram (ECG) depicted sinus rhythm (SR) with left axis deviation and slow progression of R-waves in V1-4. Transthoracic echocardiography (TTE) revealed a normal left ventricle ejection fraction (LVEF) of 0.64, LV hypertrophy, inferior wall hypokinesia, biatrial dilatation, mild mitral and tricuspid regurgitation with normal estimated pulmonary artery pressure of 20 mmHg. On routine ETT 120% of target exercise tolerance was reached and 87% of the maximal heart rate. He developed EI-LBBB at frequency of 80 bpm, which lasted, through the third minute of the recovery period, till the end of the test at a heart rate of 83 bpm. At coronary angiography, significant stenoses were found in the left anterior descending and circumflex coronary arteries. Percutaneous coronary intervention was performed and both lesions were dilated with placement of DES. Accordingly a drug therapy was started composed of aspirin for 1 mo, clopidogrel for 1 year and oral anticoagulant, lipid lowering drug, hydrochloorthiazide and irbesartan as a maintenance drug regimen.....