A misc PEARL: for heart failure with preserved ejection fraction: afterload reduction (eg wtih ACEi) is not as helpful as in HFrEF!
New LBBB ddx
- MI, MI, MI should be top 1, 2, and 3 diagnoses!
- Don’t forget to check lateral leads (for MI in the high lateral distribution)!
- A refresher on scarbossa’s criteria below!
- Rate-related LBBB (from conduction disease)
- Ischemic MR (from LCx or dominant RCA ischemia).
- *What is “silent MR”? About 50% of patients with new mod/severe acute MR don’t’ have a murmur, esp with ischemic MR – mechanism is thought to be from relatively low systolic pressure gradient between the LV and LA (from low SBP and elevated L atrial pressure)
Scarbossa’s criteria for MI in setting of new LBBB (specific but not sensitive!!)
- Concordant ST elevation >1mm (score 5)
- Concordant ST depression >1mm in V1-V3 (score 3)
- DISCORDANT ST elevation >5mm (score 2)
- Jen Olenik’s mnemonic (take it or leave it!): “5D11C” – aka 5mm discordant, 1mm concordant
- Here is a visual, from http://lifeinthefastlane.com/ecg-library/basics/sgarbossa/:
For a new diastolic murmur, think:
- Aortic disease (eg ascending aortic dissection – should be hypotensive!)
- Valvulopathy (eg endocarditis)
- *Aortic insufficiency: classically associated with a diastolic murmur’ often also hear a “whooshing” systolic murmur!
- Infections (of course!)
- Chronic, eg TB
- While I cannot access this 1956 article, I had to share, based on HH’s PEARL about how they used to collect blood from the earlobe to make smears looking for monocytes in pts with suspected subacute bacterial endocarditis: http://www.ncbi.nlm.nih.gov/pubmed/13376980 “Hematologic observations in bacterial endocarditis, especially the prevalence of histiocytes and the elevation and variation of the white cell count in blood from the ear lobe.”
- And a 1964 Ann Internal Medicine article on the same! http://annals.org/article.aspx?articleid=679421