LBBB on ekg

[coffeebythelake]

i've always learned that a "new" LBBB should be considered worthy of cardiac evaluation. pt's from the community i've taken care of who have "old" known LBBB almost invariably have stress-test or other cardiac evaluation reports which adds a certain degree of reassurance for me. but per ACC/AHA guidelines, LBBB is consider a "minor clinical predictor" of perioperative cardiac complications (which would make it fall within the same category as LVH, non-specific ST-T changes, etc). a problem i see is that LBBB may obscure ST changes that may occur with ischemia, or at least require high level analysis to discern (ala Sgarbossa critera)

but in real life... what would you do in these circumstances?

70 y.o. obese pt with multiple minor risk factors (e.g., older male, DLP, HTN) going for elective moderate risk surgery. Recent normal EKG's last one 6 months ago, before induction of GA found to have LBBB. equivocal functional status. no other hx of cardiac evaluations or studies. cancel or proceed with case?

same case except that the patient was NSR initially but then develops LBBB intraop. maintained close hemodynamic stability during rest of case and then you extubate. denies chest pain postop. what kind of workup (if any) would you do here?

lets hear your opinions--

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[deleted59964]

... in real life... what would you do in these circumstances?

1... 70 y.o. obese pt with multiple minor risk factors (e.g., older male, DLP, HTN) going for elective moderate risk surgery. Recent normal EKG's last one 6 months ago, before induction of GA found to have LBBB. equivocal functional status. no other hx of cardiac evaluations or studies. cancel or proceed with case?


2. same case except that the patient was NSR initially but then develops LBBB intraop. maintained close hemodynamic stability during rest of case and then you extubate. denies chest pain postop. what kind of workup (if any) would you do here?

1. elective surgery + new LBBB = defer case for further work up, and optimisation if possible

2. 12 lead ECG, troponin, refer to cardiology

 

[Psai]

For 2 i would get a bmp and mg to look at lytes. Also echo for valves, dilation, wall motion abnormalities

 

[caligas]

You could use this and if above 1%, delay for testing:

Gupta Perioperative Cardiac Risk | Calculate by QxMD

 

[repititionition]

 

[coffeebythelake]

Well yes, I think most people would agree that new LBBB doesn't automatically = STEMI and Cath lab. That's not the Q here.

 

[AdmiralChz]

Interesting. At the very least you are obligated to get a 12 lead which will delay the case anyway. I can’t see anyone faulting you for getting a Cards consult if you’re concerned except a grumpy surgeon. You can tell him he’d be much more grumpier if the patient has a cardiac event intra-op.

I’ll personally wait for some input from AHA/ACC on this, rather than taking the European guidelines as new practice. For now it’s still delay the case.

 

[Shimmy8]

1. elective surgery + new LBBB = defer case for further work up, and optimisation if possible

2. 12 lead ECG, troponin, refer to cardiology

In my real life PP...this is 100% the answer and in case of #1 I would get no pushback from surgeons, and in the rare case I did, my colleagues would 10000% back me up.

 

[coffeebythelake]

So I actually had a case like #1 recently, in the OR mask on face and ready to induce. Then we saw the tracing and the QRS was widened. He had some fatigue and sob with exertion which was attributed to his asthma and sinus problems, but may very well be cardjac? I wasnt sure. Held the case, did a 12 lead to confirm LBBB, spoke with his PCP about recent normal EKG and them I cancelled the case for further evaluation.

As I mentioned before, the guidelines set by ACC/AHA would have you do otherwise. Basically in the absence of intermediate clinical risk factors (elevated cr, insulin dependent DM, CAD, stroke, CHF) and with modest functional capacity >4 METS and no active cardiac symptoms such as chest pain you should proceed with case. Even if the patient had these intermediate risk factors you might still proceed with case if you don't think an evaluation would ultimately alter your management.

Personally, I wouldn't. And the guidelines would not make me change my mind for reasons I elucidated earlier

 

[anbuitachi]

What if the LBBB isn't 'new' , is also on previous EKG, but patient has no known cardiac workup? Same thing? Cancel case for workup?
And what if patient only has 1 ekg with LBBB with no previous records? Same thing?

 

[aneftp]

1. elective surgery + new LBBB = defer case for further work up, and optimisation if possible

2. 12 lead ECG, troponin, refer to cardiology

Patient will lie.

Claim they can do more than 4 Mets without cp/sob. U look at these patients. 300 pounders huffing and puffing just getting dressed in preop holding area.

What would u do if u don’t believe the history they tell u?

Going strictly by aha/acc guidelines in these medium risk patients (obese, osa,dm etc....no known cad who flat out lie to u they can climb 2 flights of stairs.

It’s a major dilemenia

 

[deleted59964]

What if the LBBB isn't 'new' , is also on previous EKG, but patient has no known cardiac workup? Same thing? Cancel case for workup?
And what if patient only has 1 ekg with LBBB with no previous records? Same thing?

If there is no history to suggest it’s a recent development, I’d proceed.

The more urgent the procedure, the more minor it is, and the better the exercise tolerance - the better I feel about it.

 

[deleted59964]

Patient will lie.

Claim they can do more than 4 Mets without cp/sob. U look at these patients. 300 pounders huffing and puffing just getting dressed in preop holding area.

What would u do if u don’t believe the history they tell u?

Going strictly by aha/acc guidelines in these medium risk patients (obese, osa,dm etc....no known cad who flat out lie to u they can climb 2 flights of stairs.

It’s a major dilemenia

Ask them to accompany you for a walk up 2 flights of stairs.

 

[coffeebythelake]

FYI outcome of this case -

fatigue and sob with exertion which was attributed to his asthma and sinus problems. functional status probably <4 mets hard to tell. i cancelled the case before induction, sent pt to preop clinic and communicated with pcp about concerns.

i disagree with the idea that a redo sinus surgery is considered "low risk". I consider it moderate risk. i've seen these redo's with >500 cc blood loss before. i think the periop risk assessment scale that exist with these schemes is way too broad and extrapolates in a way that is not that meaningful for this case.

Anyways -- pt had a cardiac cath several days later showing severe 3 vessel CAD.
his cardiologist felt his sx were at least partly angina related.
Got a 4v CABG several weeks later.

of course this is n=1,
but not bad for a patient who didn't even know he had CAD.

 

[anbuitachi]

what about new RBBB? same thing?

 

[MoMoGesiologist]

FYI outcome of this case -

fatigue and sob with exertion which was attributed to his asthma and sinus problems. functional status probably <4 mets hard to tell. i cancelled the case before induction, sent pt to preop clinic and communicated with pcp about concerns.

i disagree with the idea that a redo sinus surgery is considered "low risk". I consider it moderate risk. i've seen these redo's with >500 cc blood loss before. i think the periop risk assessment scale that exist with these schemes is way too broad and extrapolates in a way that is not that meaningful for this case.

Anyways -- pt had a cardiac cath several days later showing severe 3 vessel CAD.
his cardiologist felt his sx were at least partly angina related.
Got a 4v CABG several weeks later.

of course this is n=1,
but not bad for a patient who didn't even know he had CAD.

Let's say you did this case and maintained his BP and HR at baseline. Would there be any difference in outcome compared to doing the case later after the CABG? As long as we maintain VS at baseline, what's the risk? Of course you may need more pressors, less anesthetic, fluids, etc.

 

[Ronin786]

Let's say you did this case and maintained his BP and HR at baseline. Would there be any difference in outcome compared to doing the case later after the CABG? As long as we maintain VS at baseline, what's the risk? Of course you may need more pressors, less anesthetic, fluids, etc.

The risk is this guy dies on induction. It doesn't have to be hypotension or tachycardia that does him in, surgery in and of itself and its inflammatory state can predispose this patient to a preoperative MI. Even if it doesn't happen on POD #0.

Also the mortality benefit is not necessarily from revascularization but rather from medical "optimization". Unfortunately, if I'm not mistaken, it's only been studied in patients undergoing vascular surgery and not so much lesser procedures.

 

[coffeebythelake]

Let me posit to you a few scenario/permutations of this case.
In bold is what I would do...

1. Cancel case, cath showed severe 3v CAD, sx the same, seen by cardiologist who started pt on BB (or something else), sent back with studies + letter of medical optimization and okay to proceed with elective surgery. Yes I would proceed with case cautiously (a-line, stable induction, etc).

2. Cancel case, cath showed severe 3v CAD, sx the same, seen by cardiologist who felt pt should get CABG but okay to do this elective case first. Sent back with studies + letter saying okay to proceed with elective surgery. Yes I would proceed with case cautiously (a-line, stable induction, etc).

3. Do not cancel case, do the case assuming cardiac risk, pt does fine, explain in PACU that pt needs to be seen by cardiologist for evaluation. Pt ultimately has cath showing severe 3v CAD, gets medically managed or CABG. I think in this scenario it would be difficult to explain why the patient all of a sudden needs to be seen by cardiologist after the elective surgery if "nothing bad happened". And if something actually goes wrong I think it might be hard to defend the course of action despite whatever ACC/AHA guidelines that exist. I remind you that this patient does not even know he has CAD.

4. (similar to 1 and 2), Pt has known severe CAD for many years and managed. Saw his cardiologist in the past 6 months when his sx were about the same. Yes I would proceed with case cautiously...

5. Pt has known severe CAD for many years and managed. Saw his cardiologist in the past 6 months but sx have significantly worsened since then. Clarify sx, but most likely cancel case and send to cardiologist for eval.

 

[NightNight]

FYI outcome of this case -

fatigue and sob with exertion which was attributed to his asthma and sinus problems. functional status probably <4 mets hard to tell. i cancelled the case before induction, sent pt to preop clinic and communicated with pcp about concerns.

i disagree with the idea that a redo sinus surgery is considered "low risk". I consider it moderate risk. i've seen these redo's with >500 cc blood loss before. i think the periop risk assessment scale that exist with these schemes is way too broad and extrapolates in a way that is not that meaningful for this case.

Anyways -- pt had a cardiac cath several days later showing severe 3 vessel CAD.
his cardiologist felt his sx were at least partly angina related.
Got a 4v CABG several weeks later.

of course this is n=1,
but not bad for a patient who didn't even know he had CAD.

This was a good catch, for this patient. I guess the question is how often, with a similar patient, is a work-up going to reveal severe CAD indicating CABG? I don’t think you did the wrong thing, just asking.

 

[coffeebythelake]

This was a good catch, for this patient. I guess the question is how often, with a similar patient, is a work-up going to reveal severe CAD indicating CABG? I don’t think you did the wrong thing, just asking.

i don't cancel cases often (maybe once a year) and i deal with more than a fair share of pts who are cardiac cripples, severe pHTN, CHF, severe CAD, etc... i think clinical context is important. if the patient had a LBBB of unknown duration but otherwise had great functional capacity (the better the METs the more reassured I feel, but definitely >4 METs,) i would proceed with case. the patient's history and symptoms were more suspicious in this case.

don't get me started on how I think "walking up flight of stairs = >4 METs" is a horribly subjective way of assessing cardiopulmonary fitness

 

[nimbus]

The risk is this guy dies on induction. It doesn't have to be hypotension or tachycardia that does him in, surgery in and of itself and its inflammatory state can predispose this patient to a preoperative MI. Even if it doesn't happen on POD #0.

Also the mortality benefit is not necessarily from revascularization but rather from medical "optimization". Unfortunately, if I'm not mistaken, it's only been studied in patients undergoing vascular surgery and not so much lesser procedures.

He didn’t die on induction for his cabg. It is exceedingly rare. Just sayin’

An interesting observation is that many, perhaps even a majority of CABG patients have normal EKGs.

Agree EKG findings have to be interpreted within the context of other clinical signs and symptoms.

 

[vector2]

The risk is this guy dies on induction. It doesn't have to be hypotension or tachycardia that does him in, surgery in and of itself and its inflammatory state can predispose this patient to a preoperative MI. Even if it doesn't happen on POD #0.

Also the mortality benefit is not necessarily from revascularization but rather from medical "optimization". Unfortunately, if I'm not mistaken, it's only been studied in patients undergoing vascular surgery and not so much lesser procedures.

Can't quote this post enough. The risk with these patients is not just a type 2 MI (demand ischemia) from hemodynamic instability, but rather that they are also predisposed to type 1 MI (plaque rupture) due to the highly inflammatory state that is created the second a knife starts violating mucous membranes and vasculature. The even scarier part is that incidence of perioperative MI is biphasic- plaque rupture peaks with lower grade (50%) stenosis vs demand MI with high grade (70%).

 

[vector2]

He didn’t die on induction for his cabg. It is exceedingly rare. Just sayin’

An interesting observation is that many, perhaps even a majority of CABG patients have normal EKGs.

Agree EKG findings have to be interpreted within the context of other clinical signs and symptoms.

I would argue that so many CABG pts do well perioperatively nowadays because they're all on bb, asa, statin preop, and also bc most centers give a full dose asa a few hours after they hit the ICU.

 

[coffeebythelake]

what about new RBBB? same thing?

etiology of RBBB is much less likely to be ischemic, so probably not.

recalling my internal medicine days, RBBB pattern is rarely of concern except if its brugada syndrome

 

[Psai]

etiology of RBBB is much less likely to be ischemic, so probably not.

recalling my internal medicine days, RBBB pattern is rarely of concern except if its brugada syndrome

Had a patient with chest pain and new rbbb, leaked a trop that night, cath showed severe lad. I used to think rbbb was nbd until that patient.

 

[coffeebythelake]

Interesting. But I think in that particular scenario the chest pain itself would have prompted a cardiac eval irrespective of RBBB

 

[Psai]

Interesting. But I think in that particular scenario the chest pain itself would have prompted a cardiac eval irrespective of RBBB

For sure and we shouldn't practice anecdotal medicine but I still take new rbbb more seriously

 

[coffeebythelake]

For sure and we shouldn't practice anecdotal medicine but I still take new rbbb more seriously

I've learned over the years that there is no such thing as absolutes in medicine. For instance, I say rarely or very unlikely, but I never say never.

Anecdotes are the instances where things aren' always exactly like the textbooks. While you shouldn't take them for the norm, I show you the outliers that can exist

 

[anbuitachi]

I dont know the prevelances of each, but if you look at the list of etiology of RBBB, a lot of them are pretty bad. From LIFL:
Causes of RBBB

• Right ventricular hypertrophy / cor pulmonale
• Pulmonary embolus
• Ischaemic heart disease
• Rheumatic heart disease
• Myocarditis or cardiomyopathy
• Degenerative disease of the conduction system
• Congenital heart disease (e.g. atrial septal defect)

It would help if it had the prevalence though