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Acute chest pain in a patient with left bundle branch pacing

Joseph Allencherril1, Salman Bandeali1, Kjell Nikus2

  • 1Texas Heart Institute, Houston, TX, USA.

Journal of Electrocardiology
|January 11, 2023
PubMed

Insights

Left bundle branch pacing can mimic ST elevation myocardial infarction (STEMI) on ECG. ST-segment deviation during LBB pacing should not be ignored, as it may indicate coronary occlusion despite not meeting Sgarbossa criteria.

Area of Science:

  • Cardiology
  • Electrophysiology
  • Diagnostic Imaging

Background:

  • Left bundle branch (LBB) electronic ventricular pacing is increasingly used.
  • ECG interpretation during LBB pacing presents diagnostic challenges, particularly for ST-segment elevation myocardial infarction (STEMI).
  • The Sgarbossa criteria are typically used to diagnose STEMI in patients with ventricular pacing but may not be applicable to LBB pacing.

Observation:

  • A patient undergoing LBB pacing presented with chest pain and inferolateral ST elevation on ECG.
  • Initial assessment suggested the Sgarbossa criteria for STEMI were not met.
  • Persistent symptoms prompted emergency coronary angiography.

Findings:

  • Coronary angiography revealed a complete occlusion of the left circumflex artery.
  • LBB pacing characteristically produces narrow QRS complexes with incomplete right bundle branch block morphology.
  • ST-segment deviations in this context warrant careful consideration beyond standard STEMI criteria.

Implications:

  • ST-segment deviation during LBB pacing should not be disregarded, even if Sgarbossa criteria are unmet.
  • The Sgarbossa criteria may not be suitable for diagnosing STEMI in patients with LBB pacing.
  • This case highlights the need for clinical correlation and potentially urgent angiography in LBB-paced patients with ischemic symptoms and ECG changes.

Keywords:
LBB pacingST elevationSTEMI

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