Exercise-Induced Chest Pain: Ischemia or Something Else

ECG Challenge

A 59-year-old man presented to the emergency department with exertional chest pain for 1 week. He had a history of hypertension with good blood pressure control. The patient was hemodynamically stable and appeared only slightly uncomfortable. The cardiac and pulmonary examination results were normal. The initial ECG was normal. The results of cardiac biomarkers and D-dimer were negative. He had simultaneous onset and resolution of chest pain and left bundle branch block (LBBB) during the exercise ECG stress test (Figure). What are the important findings on the ECG? What is the most likely diagnosis?

(Enlarge Image)

Figure 1.

The ECG showed the onset (A, black arrow) and resolution (B, black arrow) of left bundle branch block during exercise ECG test.

Please turn the page to read the diagnosis.

Circulation. 2023;148(4):373-374. © 2023 American Heart Association, Inc.