681 RIGHT ARM PAIN WITH RIGHT BUNDLE BRANCH BLOCK: SHOULD WE PERFORM TROPONIN ASSAY?

Abstract We present the case report of a 67 year old man with no previous cardiovascular history, who was admitted to our emergency department (ED) for two days onset right arm pain which not responsive painkillers. On admission, he asymptomatic typical angina. His BP 190/100 mmHg, HR 80 bpm, SpO2 99% and apyretic. The clinical examination unremarkable. ECG showed sinus rhythm, complete right-bundle-branch-block (RBBB) left-axis deviation, negative T-waves in V1-V2 positive V3 > V6 (figure 1A) (no ECGs were available). blood samples normal renal function count. Surprisingly, there progressive rise troponin I levels 0.023 0.061 0.38 ng/ml (ULN 0.010 ng/ml). Echocardiography revealed preserved LVEF without major regional wall motion abnormalities (RWMA), nor any valvulopathy. Despite atypical presentation ECG, strongly suggestive an acute coronary syndrome (ACS), so patient sent Cath lab undergo angiography (CAG). At time CAG asymptomatic. exam thrombotic occlusion mid-segment left anterior descending artery (LAD). Primary PCI DES implantation performed obtaining TIMI 3 flow (figure2). remaining hospital stay uneventful, discharged after 4 days. Pre-discharge echocardiography reported RWMA. Discharge persistency RBBB from V1 V4 1B). months follow up visit is LVEF. normalization precordial leads 1C). Discussion This epicardial artery, ST segment elevation (STEMI equivalent) may represent uncommon myocardial ischemia, incidence 2 6% overall, 0 infarct-related only half cases. (especially new or presumably RBBB) also associated increased mortality morbidity, possibly due delay diagnosis primary reperfusion strategies. Troponin dosage fundamental understand that we facing syndrome, however expecting LAD. In conclusion, presence on admission strategies, especially when symptoms are atypical. However, unresponsive new-onset conduction disturbances it mandatory perform assay therefore drive correct timing revascularization.