Alternating Bundle Branch Block or Pyridostigmine-induced Mobitz Type II Block Masquerading as Acute Coronary Syndrome

ABSTRACT Background “ST-T changes in the ECG!!” These words are enough to get the emergency doctor to spring into action. These changes can be diffuse and/or non-specific but we should rule out all emergent and urgent causes before shifting the patient to the specialist. To err on the side of dangerous etiology is the dictum. Introduction Out of all emergency department (ED) patients with undifferentiated chest pain, 7% will have ECG findings consistent with acute ischemia or infarction, and 6–10% of those in whom cardiac markers are ordered will have initially positive results. Of all patients with the possible acute coronary syndrome (ACS), 5–15% ultimately prove to have ACS.1 Shortness of breath with chest pain mostly has a cardiac origin in the presence of dynamic ECG changes. We had managed a patient with rapidly evolving ECG changes, chest pain, palpitations, and grade III–IV dyspnea. In the chaotic environment of a busy ED, the most probable diagnosis here will be ACS. Comorbid conditions like diabetes mellitus, hypertension, and prior coronary artery disease (CAD) are commonly enquired. However, other long-standing illnesses like myasthenia gravis (MG), as in our patient can be easily missed if a patient is not forthcoming with history. We experienced a similar confusion when in the cacophony of chest pain, dyspnea, and T wave inversions with bundle branch blocks, ACS protocol was initiated and a simple diagnosis was missed. The significance of the alternating bundle branch block (ABBB) will be presented to the readers. How to cite this article Hymavathi A, Uppaluri SC, Sharma A. Alternating Bundle Branch Block or Pyridostigmine-induced Mobitz Type II Block Masquerading as Acute Coronary Syndrome. J Med Acad 2020;3(2):63–66.

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To Perform Thrombolysis or Not: A Case of Acute Pancreatitis Presenting with Chest Pain and Transient Left Bundle Branch Block

Case Reports in Medicine ◽

10.1155/2010/204547 ◽

2010 ◽

Vol 2010 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

S. Ullah ◽

S. Mehmood ◽

H. A. Chatha ◽

A. Mahmood

Keyword(s):

Acute Pancreatitis ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Serum Amylase ◽

Suspected Case ◽

Ecg Changes ◽

Bundle Branch Block ◽

Coronary Syndrome ◽

Laboratory Results ◽

New Onset

A suspected case of acute coronary syndrome presented with new-onset left bundle branch and first-degree heart blocks. The decision to thrombolyse was reverted as ECG changes proved to be transient within fifteen minutes of presentation. Later on the patient was diagnosed with acute pancreatitis based on laboratory results of serum amylase, confirmed on radiological investigations.

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Soluble Receptor for Advanced Glycation End Product: A Biomarker for Acute Coronary Syndrome

BioMed Research International ◽

10.1155/2015/815942 ◽

2015 ◽

Vol 2015 ◽

pp. 1-7 ◽

Cited By ~ 14

Author(s):

Louise J. N. Jensen ◽

Allan Flyvbjerg ◽

Mette Bjerre

Keyword(s):

Acute Coronary Syndrome ◽

Advanced Glycation End Products ◽

Acute Ischemia ◽

Soluble Receptor ◽

Advanced Glycation ◽

Coronary Syndrome ◽

Potential Biomarker ◽

Glycation End Products ◽

End Products ◽

Artery Disease

The receptor of advanced glycation end products (RAGE) and its ligands are linked to the pathogenesis of coronary artery disease (CAD), and circulating soluble receptor of advanced glycation end products (sRAGE), reflecting the RAGE activity, is suggested as a potential biomarker. Elevated sRAGE levels are reported in relation to acute ischemia and this review focuses on the role of sRAGE as a biomarker for the acute coronary syndrome (ACS). The current studies demonstrated that sRAGE levels are elevated in relation to ACS, however during a very narrow time period, indicating that the time of sampling needs attention. Interestingly, activation of RAGE may influence the pathogenesis and reflection in sRAGE levels in acute and stable CAD differently.

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Novel Emergency Department Risk Score Discriminates Acute Coronary Syndrome Among Chest Pain Patients With Known Coronary Artery Disease

Critical Pathways in Cardiology ◽

10.1097/hpc.0000000000000091 ◽

2016 ◽

Vol 15 (4) ◽

pp. 138-144 ◽

Cited By ~ 1

Author(s):

Matthew T. Crim ◽

Scott A. Berkowitz ◽

Mustapha Saheed ◽

Jason Miller ◽

Amy Deutschendorf ◽

...

Keyword(s):

Coronary Artery Disease ◽

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Coronary Artery ◽

Risk Score ◽

Coronary Syndrome ◽

Artery Disease ◽

Pain Patients

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Relationship Between High Glycated Hemoglobin and Severity of Coronary Artery Disease in Type II Diabetic Patients Hospitalized With Acute Coronary Syndrome

Cureus ◽

10.7759/cureus.13734 ◽

2021 ◽

Author(s):

Fahad R Khan ◽

Jabar Ali ◽

Rizwan Ullah ◽

Zair Hassan ◽

Safi Khattak ◽

...

Keyword(s):

Coronary Artery Disease ◽

Acute Coronary Syndrome ◽

Coronary Artery ◽

Glycated Hemoglobin ◽

Diabetic Patients ◽

Type Ii ◽

Coronary Syndrome ◽

Artery Disease

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Evaluation of Platelet Parameters in Patients With Coronary Artery Disease

ACTA MEDICA IRANICA ◽

10.18502/acta.v58i9.4762 ◽

2020 ◽

Author(s):

Mahdieh Mehrpouri1 ◽

Afshin Ahmad Pour ◽

Esmail Shahabi Satlsar

Keyword(s):

Risk Factors ◽

Coronary Artery Disease ◽

Acute Coronary Syndrome ◽

Coronary Artery ◽

Coronary Angiography ◽

Healthy Volunteers ◽

Ecg Changes ◽

Coronary Syndrome ◽

Significant Difference ◽

Artery Disease

Coronary artery disease (CAD) is one of the leading causes of death worldwide; therefore, identifying new risk factors to predict the severity of the disease is thought to be associated with mortality reduction. In an effort to investigate whether platelet parameters are related to the extent of CAD and can be considered as risk factors, we designed experiments to evaluate platelet parameters in these patients. In a cross‐sectional study, sixty-nine patients with CAD (including fifty-two patients with acute coronary syndrome and seventeen patients with stable angina) and sixty-four healthy volunteers were evaluated for platelet count, mean platelet volume (MPV), and platelet distribution width (PDW). Echocardiography, electrocardiogram (ECG), and coronary angiography were conducted as well. Results showed significantly higher values for MPV and PDW in patients with acute coronary syndrome as compared to patients with stable angina and healthy volunteers (P<0.001 and P=0.009, respectively). There was no significant difference in platelet count between patients and healthy volunteers (P=0.379). Our results also revealed a significant difference in the ejection fraction (EF) percentage between the three groups (P=0.008). Investigating the correlation between platelet parameters and EF percentage, ECG changes, and the results of coronary angiography did not show any significant association. The present study showed that the elevated levels of MPV and PDW in patients with CAD are not related to the extent of coronary artery disease, which was estimated by echocardiography, ECG changes, and coronary angiography. Thus, these parameters cannot be considered as risk factors for coronary artery disease.

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Abstract 157: Use of a Novel Risk Score in the Emergency Department Discriminates Acute Coronary Syndrome Among Chest Pain Patients with Known Coronary Artery Disease

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.7.suppl_1.157 ◽

2014 ◽

Vol 7 (suppl_1) ◽

Author(s):

Matthew T Crim ◽

Frederick K Korley ◽

Scott A Berkowitz ◽

Mustapha Saheed ◽

Jason Miller ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chronic Kidney Disease ◽

Chest Pain ◽

Risk Score ◽

Troponin I ◽

Elevated Troponin ◽

Ecg Changes ◽

Coronary Syndrome ◽

History Of ◽

Artery Disease

Background: Patients with known coronary artery disease (CAD) presenting to the Emergency Department (ED) with chest pain thought to be of ischemic origin are often admitted to the hospital, yet less than half are eventually diagnosed with acute coronary syndrome (ACS). We assessed whether the use of a novel risk score in the ED could discriminate which of these high-risk patients actually do or do not have ACS. Methods and Results: Chart review was performed on a prospectively defined cohort of 142 patients with known CAD presenting to the ED with chest pain thought to be of ischemic origin, all of whom were admitted to the hospital from December 2012 to April 2013. Known CAD was defined as history of myocardial infarction, PCI, CABG, angiographic coronary stenosis >50%, or a positive stress test. Troponin I was measured using the Beckman Coulter assay. Variables were assessed with logistic regression for their association with ACS as determined by the inpatient attending physician at hospital discharge. The cohort included 59 women (42%) and 90 African American individuals (63%). One-hundred sixteen patients (82%) had a history of revascularization (104 PCI, 53 CABG, 41 both). ACS was eventually diagnosed in 43 (30%) of the patients. Non-ACS patients had a 2.8 day average length of stay and $9,908 average inpatient (post-ED) hospital charges (not including physician fees), which is $980,926 for the 99 (70%) non-ACS patients. A novel risk score, including (1) elevated troponin I (>0.05 ng/mL) in the ED, (2) dynamic ECG changes in the ED, (3) body mass index (BMI), (4) home aspirin use, (5) age older than 65, (6) history of chronic kidney disease (CKD), and (7) associated illness at presentation to the ED (anemia, arrhythmia, hypertension, infection, COPD exacerbation, diabetic ketoacidosis or hyperosmolar hyperglycemic state), discriminated ACS and non-ACS with an area under ROC curve (AUC) of 0.829. In the multi-variable regression, troponin I elevation was the most predictive of ACS (OR 7.22, p <0.001), followed by home aspirin use (OR 6.07, p 0.036), age older than 65 (OR 4.06, p 0.012), dynamic ECG changes (OR 2.68, p 0.046), and BMI (OR 1.09, p 0.008). The presence of an associated illness was associated with decreased likelihood of ACS (OR 0.24, p 0.013), as was CKD (OR 0.17, p 0.008). Conclusions: A novel risk score including elevated troponin I in the ED, dynamic ECG changes in the ED, body mass index, home aspirin use, age older than 65, history of chronic kidney disease, and associated illness at presentation to the ED, is a valuable tool for discriminating between ACS and non-ACS among patients with known CAD presenting to the ED with chest pain. This preliminary analysis provides a foundation for larger and prospective studies for validation. Application of this risk score, along with other clinical factors, may reduce the number of potentially avoidable admissions and associated costs.

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