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VOLUME 3 , ISSUE 2 ( July-December, 2020 ) > List of Articles

CASE REPORT

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

Akula Hymavathi, Sarat C Uppaluri, Ashima Sharma

Keywords : Infarction, Retrosternal,Coronary syndrome

Citation Information : Hymavathi A, Uppaluri SC, Sharma A. Alternating Bundle Branch Block or Pyridostigmine-induced Mobitz Type II Block Masquerading as Acute Coronary Syndrome. Journal of Medical Academics 2020; 3 (2):63-66.

DOI: 10.5005/jp-journals-10070-0060

License: CC BY-NC 4.0

Published Online: 08-03-2021

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


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.


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  1. Chest Pain. Rosen's Emergency Medicine. Concepts and clinical practice, ed. Marx JA, Hockberger RS, Wells RM 8th ed., Elseivier Publications, 2012.
  2. The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emeregency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India. J Emerg Trauma Shock 2017;10(2):74-81. DOI: 10.4103/JETS.JETS_148_16.
  3. Chest Pain. Emergency Medicine. In: Tintinalli JE ed. A Comprehensive Study Guide, 9th ed., McGraw Hill Publications.
  4. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST segment elevation. Eur Heart J 2012;30(20):2569-2619. DOI: 10.1093/eurheartj/ehs215.
  5. 2013 ACCF/AHA Guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61(4):e78-e140. DOI: 10.1016/j.jacc.2012. 11.019.
  6. Alternating bundle-branch block in acute coronary syndrome. Cor Vasa 2019;61(1):e68-e71. DOI: 10.1016/j.crvasa.2017.12.013.
  7. High-grade atrioventricular block in acute coronary syndromes: insights from the Global Registry of Acute Coronary Events. Eur Heart J 2015;36(16):976-983. DOI: 10.1093/eurheartj/ehu357.
  8. Cardiac manifestations of myasthenia gravis: A systematic review. IJC Metabolic & Endocrine 2014;5:3-6. DOI: 10.1016/j.ijcme.2014.08.003.
  9. Broken heart syndrome in myasthenia gravis. Muscle Nerve 2011;44(6):990-993. DOI: 10.1002/mus.22220.
  10. A case of transient left ventricular ballooning (“Takotsubo”-shaped cardiomyopathy) developed during plasmapheresis for treatment of myasthenic, crisis. Rinsho Shinkeigaku 2004;44:207-210.
  11. Pyridostigmine-induced high grade SA-block in a patient with myasthenia gravis. Am J Case Rep 2013;14:359-361. DOI: 10.12659/AJCR.889484.
  12. Coronary vasospasm secondary to hypercholinergic crisis: an iatrogenic cause of acute myocardial infarction in myasthenia gravis. Int J Cardiol 2005;103(3):333-339. DOI: 10.1016/j.ijcard.2004.06.026.
  13. Non-coronary myocardial infarction in myasthenia gravis: case report and review of the literature. World J Cardiol 2013;5(7):265-269. DOI: 10.4330/wjc.v5.i7.265.
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