Felix J. Rogers

Intermittent left bundle branch block: an overlooked cause of electrocardiographic changes that mimic high-grade stenosis of the left anterior descending coronary artery.

CONTEXT The electrocardiographic (ECG) pattern of high-grade stenosis of the left anterior descending coronary artery (LAD) is important clinically because of the high risk of myocardial infarction and cardiac death if the pattern is not recognized. Although the recognition of this pattern is currently widespread, false-positive ECG changes that mimic this pattern are infrequently reported. OBJECTIVE To demonstrate that ECG changes from intermittent left bundle branch block (LBBB) and cardiac memory can mimic anterior ischemia. METHODS Medical record review of cardiology patients in whom ECG tracings showed intermittent LBBB and anterior T-wave changes during normal QRS conduction. Patients were included if ECG changes suggestive of high-grade LAD stenosis in leads V2 and V3 met the following criteria: (1) the QRS conduction was essentially normal during periods of absent LBBB; (2) the ST segment took off from an isoelectric point or only slightly elevated from baseline; and (3) the ST segment sloped up gradually with an abrupt and sharp down stroke leading to terminal T-wave inversion. Additional criteria were little or no ST segment elevation, no loss of precordial R waves, and ECG changes suggestive of high-grade LAD stenosis demonstrated in precordial leads V2 and V3. All patients demonstrated intermittent LBBB, and patients were excluded if a ventricular pacemaker was present. The case series began in 2003 and continued until 2011. RESULTS Sixteen patients (3 male) with intermittent LBBB were identified with ST- and T-wave changes during normal ventricular conduction that matched the pattern described by Hein J.J. Wellens, MD. Of these patients, none had evidence of clinically substantial coronary artery disease. Eleven patients had stress testing with myocardial perfusion imaging, and 5 patients underwent cardiac catheterization. In 1 patient whose ECG pattern showed high-grade LAD stenosis but normal coronary arteries at catheterization, a stress test was later performed, which provoked LBBB. All other patients had spontaneous, intermittent periods of LBBB and normal conduction. CONCLUSION The ECG pattern of high-grade LAD stenosis has proven to be an important marker of high-risk patients with chest pain. This pattern may also be seen in patients with a right ventricular pacemaker on resumption of native QRS conduction. Intermittent LBBB is a less obvious cause of a similar ECG pattern that may mimic anterior ischemia due to high-grade stenosis.

Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical condition. Initially called diastolic heart failure, it soon became clear that this condition is more than the opposite side of systolic heart failure. It is increasingly prevalent and lethal. Currently, HFpEF represents more than 50% of heart failure cases and shares a 90-day mortality and readmission rate similar to heart failure with reduced ejection fraction. Heart failure with preserved ejection fraction is best considered to be a systemic disease. From a cardiovascular standpoint, it is not just a stiff ventricle. A stiff ventricle combined with a stiff arterial and venous system account for the clinical manifestations of flash pulmonary edema and the marked changes in renal function or systemic blood pressure with minor changes in fluid volume status. No effective pharmacologic treatments are available for patients with HFpEF, but an approach to the musculoskeletal system has merit: the functional limitations and exercise intolerance that patients experience are largely due to abnormalities of peripheral vascular function and skeletal muscle dysfunction. Regular exercise training has strong objective evidence to support its use to improve quality of life and functional capacity for patients with HFpEF. This clinical review summarizes the current evidence on the pathophysiologic aspects, diagnosis, and management of HFpEF.

A Turning Point for Scholarly Osteopathic Publications

The Journal of the American Osteopathic Association October 2013 | Vol 113 | No. 10 The resignation of Gilbert E. D’Alonzo Jr, DO, as editor in chief of the American Osteopathic Association (AOA)1 presents 2 challenges, each of them daunting. Clearly the first challenge is to find his replacement. The AOA has had just a handful of editors in its history, and Dr D’Alonzo will be leaving a remarkable legacy. Appropriately, a search committee has initiated a national search for his successor. For this first challenge, one easy starting point for the search committee would be to begin with a list of some of the attributes and accomplishments of Dr D’Alonzo. He is a superb clinician, a nationally renowned expert in pulmonary medicine, an educator, a researcher, and an author. As editor in chief, he provided sympathetic and encouraging support for the component of our profession that practices traditional osteopathic manipulative medicine. He called for scientific rigor in all aspects of the AOA publications, from student abstracts to scholarly research articles. He promoted osteopathic medicine to the wider medical community and to the general public through vehicles such as the AOA’s custom publications and The DO magazine. And, importantly, he expanded the publication of osteopathic medical research in The Journal of the American Osteopathic Association (JAOA) and extended its scope to include evidence-based clinical reviews, summaries of the worldwide research in manipulative medicine (“The Somatic Connection”), and a section that touches on the humanistic components of the practice of osteopathic medicine (“In Your Words”). The second challenge is to explore and enhance the role of scholarly publications in the overall mission of osteopathic medicine. As a full-fledged medical institution, osteopathic medicine is expected to encompass and embrace clinical service, education, research, and scholarly publications. Traditionally, the success of the osteopathic medical profession has rested on clinical service. The earliest efforts of the AOA were to secure full practice rights for osteopathic physicians; osteopathic medicine’s prominent role in health care today rests on our achievements in the delivery of patient care. Recently, the profession has sought to expand its offerings in medical education to help meet the anticipated physician shortage. The number of colleges of osteopathic medicine (COMs) draws on our successful programs for training primary care physicians. Recognizing that our tenets and practices need to be verified by research, the profession has made incremental steps to demonstrate the worth of our educational programs and to document the scientific basis and clinical evidence in support for our practice patterns. The 2013-2022 Strategic Research Plan described by Drs Degenhardt and Standley2 represents a comprehensive roadmap to foster research throughout the osteopathic medical profession in language that expresses the urgency of the problem. Scholarly publications are the obligatory and unifying component for each aspect of clinical practice, education, and research. In one sense, scholarly publication is just like documentation in the patient bedside record, where it is said, “If it’s not documented, it didn’t happen.” Osteopathic medicine has thrived for more than 100 years, but each year it faces increasing demands from patients, third-party payers, and government regulators. Unless we document our effectiveness, confirm our uniqueness, and provide scientific evidence for our distinctive approach to patient care, we will be at risk of losing our place in the medical profession. The world of medicine has grown increasingly complex, and there is no single, easy fix. Scholarly publications alone cannot meet the needs of the osteopathic medical profession. After all, the role of such scientific reports is to document innovative educational processes, unique and effective clinical treatment, and the scientific basis of osteopathic medical care. If the research isn’t there, even the slickest medical publication won’t make up for that deficiency. A Turning Point for Scholarly Osteopathic Publications