Intermittent left bundle branch block caused by coronary vasospasm
A 53-year-old African American female with past medical history of diabetes mellitus, hypertension and dyslipidemia, presented to the hospital with 3 days history of intermittent chest pain. She described the pain as severe retrosternal, non-exertional, radiating to the left arm lasting for 20-30 min and is associated with severe diaphoresis and shortness of breath. It used to occur 3-5 times a day and relieved spontaneously or by sublingual Nitroglycerin (NTG). The patient had 15 pack year's history of smoking, occasional alcohol intake and no illicit drug use.\nOn physical examination, she was hemodynamically stable, blood pressure of 115/52 mmHg, pulse of 78 bpm, with normal saturation on room air. The pain quickly resolved by sublingual nitroglycerin and IV morphine, cardiac exam showed 2/6 systolic ejection murmur at aortic area with no radiation, heart sounds were normal with regular rate and rhythm, there was no jugular venous distention, lungs were clear, pulses were strong and equal in all limbs and there was no edema in the lower extremities. Serial EKG/ECG were obtained, it consistently showed (LBBB) during chest pain episodes [], and resolution of the LBBB pattern with deep T wave inversion in Leads V1-V4 during chest-pain-intervals [].\nPatient was started on aspirin 325 mg, loading dose of clopidogrel 600 mg, heparin drip, and was subsequently taken for emergent coronary angiogram. By the time, she arrived to Cath Lab, the chest pain was substantially improved. The coronary angiogram showed clean coronary arteries except of 80% LAD vasospasm, which was relieved by intravenous nitroglycerin. Cardiac enzymes were negative. Echocardiogram showed normal left ventricular ejection fraction without any regional wall motion abnormalities. The diagnosis of coronary vasospasm was made and the patient was started on calcium channel blocker (Diltiazem) daily, which provided symptomatic relief. Patient did well during 10 months follow-up period with further chest pain episodes.