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Acute myocardial infarction in the setting of left bundle branch block: Chapman's sign

Amr Idris1, Mohamad Hatahet1, Basel Edris2

  • 1University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA; North Florida Regional Medical Center, Internal Medicine, Gainesville, FL, USA.

The American Journal of Emergency Medicine
|August 10, 2019
PubMed

Insights

Diagnosing acute myocardial infarction (AMI) in patients with left bundle branch block (LBBB) is challenging. Chapman's sign on ECG may indicate myocardial ischemia, prompting crucial emergent treatment for acute coronary syndrome (ACS).

Area of Science:

  • Cardiology
  • Emergency Medicine

Background:

  • Diagnosing acute myocardial infarction (AMI) in patients with pre-existing left bundle branch block (LBBB) presents significant clinical challenges.
  • Delayed or missed AMI diagnosis in LBBB patients increases risks of shock, mechanical complications, and mortality.

Observation:

  • A 77-year-old male with known LBBB and prior coronary artery bypass surgery presented with chest pain and dyspnea.
  • Electrocardiogram (ECG) revealed a new Chapman's sign (notch in R wave upslope, leads I, AVL), suggestive of myocardial ischemia.
  • Initial troponin levels were normal, but serial measurements indicated elevated enzymes, confirming acute coronary syndrome (ACS).

Findings:

  • Chapman's sign on ECG can be a critical indicator of myocardial ischemia in patients with LBBB.
  • Serial troponin monitoring is essential for detecting AMI when initial levels are non-diagnostic.

Implications:

  • Physicians must recognize Chapman's sign in patients with LBBB and chest pain for timely ACS diagnosis.
  • Prompt identification and treatment of ACS in this high-risk population can improve patient outcomes.
  • This case highlights the importance of ECG findings in conjunction with biochemical markers for complex cardiac diagnoses.

Keywords:
Acute myocardial infarctionChapman's signLeft bundle branch block

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