University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA; North Florida Regional Medical Center, Internal Medicine, Gainesville, FL, USA.
University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA; North Florida Regional Medical Center, Internal Medicine, Gainesville, FL, USA.
Am J Emerg Med. 2019 Oct;37(10):1991.e5-1991.e7. doi: 10.1016/j.ajem.2019.158378. Epub 2019 Jul 29.
Acute myocardial infarction (AMI) diagnosis in patients with pre-existing left bundle branch block (LBBB) can be difficult. Undiagnosed or delayed diagnosis of AMI in these patients can put them at risk of having shock, mechanical complications, and death. We present a case of 77-year-old Caucasian male with a known LBBB and coronary artery bypass surgery for coronary artery disease who presented to the emergency department with a chief complaint of chest pain and shortness of breath. The patient had recurrent chest pain despite using aspirin, nitroglycerine, and morphine. An electrocardiogram (ECG) showed a new notch in the upslope of the R wave in leads I, AVL that indicated a positive Chapman's sign. Troponin levels were initially normal, but serial troponin showed elevated enzyme giving evidence of acute coronary syndrome (ACS). The patient was started on heparin drip and underwent subsequent coronary catheterization. Physicians should be aware of Chapman's sign on ECG in patients presenting with chest pain who have baseline LBBB as it might represent myocardial ischemia and warrant emergent treatment for ACS.
急性心肌梗死（AMI）在伴有预先存在的左束支传导阻滞（LBBB）的患者中的诊断可能较为困难。这些患者的 AMI 未被诊断或延迟诊断可能使他们面临休克、机械并发症和死亡的风险。我们报告了 1 例 77 岁的白人男性，患有已知的 LBBB 和因冠状动脉疾病而行冠状动脉旁路手术，因胸痛和呼吸急促就诊于急诊科。尽管使用了阿司匹林、硝酸甘油和吗啡，患者仍反复出现胸痛。心电图（ECG）显示 I 导联、AVL 导联 R 波上升支出现新切迹，提示 Chapman 征阳性。肌钙蛋白水平最初正常，但连续检测发现肌钙蛋白升高，提示急性冠状动脉综合征（ACS）。患者开始接受肝素滴注，并随后进行了冠状动脉造影。对于基线 LBBB 且伴有胸痛的患者，心电图上Chapman 征提示心肌缺血，需要紧急治疗 ACS，医生应意识到这一点。
