AM <3 report PEARLS: LBBB ddx, diastolic murmurs (and monocytosis ddx)

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!
    1. Don’t forget to check lateral leads (for MI in the high lateral distribution)!
    2. A refresher on scarbossa’s criteria below!
  • Rate-related LBBB (from conduction disease)
  • Ischemic MR (from LCx or dominant RCA ischemia).
    1. *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


For a new diastolic murmur, think:

  • Aortic disease (eg ascending aortic dissection – should be hypotensive!)
  • Valvulopathy (eg endocarditis)
    1. *Aortic insufficiency: classically associated with a diastolic murmur’ often also hear a “whooshing” systolic murmur!


Monocytosis ddx

  • Neoplastic
  • Drugs
  • Infections (of course!)
    • Viral
    • Chronic, eg TB
    • Endocarditis
      • 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: “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!


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