{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T15:50:09Z","timestamp":1753890609965,"version":"3.41.2"},"reference-count":22,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,1,8]],"date-time":"2025-01-08T00:00:00Z","timestamp":1736294400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Painful left bundle branch block (LBBB) syndrome is an uncommon disease that is defined as intermittent episodes of angina associated with simultaneous LBBB changes on an electrocardiogram (ECG) with the absence of flow-limiting coronary artery disease or ischemia on functional testing. Vasovagal syncope (VVS) is the most common cause of syncope and can be provoked by sublingual nitroglycerin (NTG). Herein, we report a case of painful LBBB syndrome complicated with VVS, which was misdiagnosed as acute coronary syndrome and cardiogenic shock.<\/jats:p><\/jats:sec><jats:sec><jats:title>Case summary<\/jats:title><jats:p>A 62-year-old woman presented with intermittent exertional chest pain for 3\u2005years and deteriorated for 2\u2005weeks. An ECG, transthoracic echocardiography, and laboratory test results were all normal. Exercise treadmill testing induced chest pain, accompanied by new-onset LBBB. She fainted after finishing the test and receiving sublingual NTG, with a rapid decline in heart rate and blood pressure, which was relieved by 0.5\u2005mg of atropine administered intravenously. Coronary angiography showed no evidence of obstructive lesions. Isoprenaline stress echocardiography induced chest pain and rate-dependent LBBB and showed interventricular\/intraventricular desynchrony simultaneously. A head-up tilt test verified mixed VVS in the provocative phase. A diagnosis of painful LBBB syndrome complicated with VVS induced by sublingual NTG was made. The patient received an extended-release metoprolol succinate tablet and had no symptoms at a 1-year follow-up.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Painful LBBB syndrome is an uncommon cause of chest pain and is often overlooked by physicians. Misdiagnosis and mistreatment of painful LBBB syndrome may even cause secondary damage, such as VVS induced by sublingual NTG, which is usually used to alleviate angina.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fcvm.2024.1438320","type":"journal-article","created":{"date-parts":[[2025,1,8]],"date-time":"2025-01-08T06:16:37Z","timestamp":1736316997000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Case Report: Painful left bundle branch block syndrome complicated with vasovagal syncope"],"prefix":"10.3389","volume":"11","author":[{"given":"Jiangying","family":"Luo","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yajun","family":"Xue","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fang","family":"Liu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jing","family":"Yang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Boda","family":"Zhou","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ping","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,1,8]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1559","DOI":"10.1136\/heartjnl-2018-314673","article-title":"Diagnosis of acute myocardial infarction in the presence of left bundle branch block","volume":"105","author":"Nestelberger","year":"2019","journal-title":"Heart"},{"key":"B2","doi-asserted-by":"publisher","first-page":"3720","DOI":"10.1093\/eurheartj\/ehad191","article-title":"2023 ESC Guidelines for the management of acute coronary syndromes","volume":"44","author":"Byrne","year":"2023","journal-title":"Eur Heart J"},{"key":"B3","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1378\/chest.69.1.123","article-title":"Rate-dependent left bundle branch block with angina pectoris and normal coronary arteriograms","volume":"69","author":"Vieweg","year":"1976","journal-title":"Chest"},{"key":"B4","doi-asserted-by":"publisher","first-page":"359","DOI":"10.4330\/wjc.v5.i9.359","article-title":"Exercise-induced left bundle branch block: an infrequent phenomenon: report of two cases","volume":"5","author":"Said","year":"2013","journal-title":"World J Cardiol"},{"key":"B5","doi-asserted-by":"publisher","first-page":"326","DOI":"10.1378\/chest.81.3.326","article-title":"Chest pain and rate-dependent left bundle branch block in patients with normal coronary arteriograms","volume":"81","author":"Virtanen","year":"1982","journal-title":"Chest"},{"key":"B6","doi-asserted-by":"publisher","first-page":"226","DOI":"10.1016\/j.hrthm.2015.08.001","article-title":"Painful left bundle branch block syndrome: clinical and electrocardiographic features and further directions for evaluation and treatment","volume":"13","author":"Shvilkin","year":"2016","journal-title":"Heart Rhythm"},{"key":"B7","doi-asserted-by":"publisher","first-page":"335","DOI":"10.1016\/j.tcm.2018.10.012","article-title":"Mechanism of harm from left bundle branch block","volume":"29","author":"Smiseth","year":"2019","journal-title":"Trends Cardiovasc Med"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1615","DOI":"10.1016\/S0735-1097(02)02337-9","article-title":"Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony","volume":"40","author":"Pitzalis","year":"2002","journal-title":"J Am Coll Cardiol"},{"key":"B9","doi-asserted-by":"publisher","first-page":"191","DOI":"10.1016\/j.echo.2008.01.003","article-title":"Echocardiography for cardiac resynchronization therapy: recommendations for performance and reporting\u2013a report from the American Society of Echocardiography Dyssynchrony Writing Group endorsed by the Heart Rhythm Society","volume":"21","author":"Gorcsan","year":"2008","journal-title":"J Am Soc Echocardiogr"},{"key":"B10","doi-asserted-by":"publisher","first-page":"1019","DOI":"10.1016\/j.jelectrocard.2018.08.014","article-title":"Painful left bundle branch block syndrome treated with his bundle pacing","volume":"51","author":"Viles-Gonzalez","year":"2018","journal-title":"J Electrocardiol"},{"key":"B11","doi-asserted-by":"publisher","first-page":"439","DOI":"10.1016\/j.hrcr.2018.08.005","article-title":"Painful left bundle branch block [corrected] syndrome treated successfully with permanent His bundle pacing","volume":"4","author":"Suryanarayana","year":"2018","journal-title":"HeartRhythm Case Rep"},{"key":"B12","doi-asserted-by":"publisher","first-page":"568","DOI":"10.1016\/j.jaccas.2019.11.081","article-title":"Painful left bundle branch block syndrome successfully treated with left bundle branch area pacing","volume":"2","author":"Garg","year":"2020","journal-title":"JACC Case Rep"},{"key":"B13","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1016\/j.hrcr.2019.03.005","article-title":"Treatment of painful left bundle branch block syndrome with cardiac resynchronization therapy or right-ventricular pacing","volume":"5","author":"Sroubek","year":"2019","journal-title":"HeartRhythm Case Rep"},{"key":"B14","doi-asserted-by":"publisher","first-page":"317","DOI":"10.1097\/00000441-198611000-00013","article-title":"Rate-related left bundle branch block with chest pain and normal coronary arteriograms treated by exercise training","volume":"292","author":"Heinsimer","year":"1986","journal-title":"Am J Med Sci"},{"key":"B15","doi-asserted-by":"publisher","first-page":"3427","DOI":"10.1093\/eurheartj\/ehab364","article-title":"2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy","volume":"42","author":"Glikson","year":"2021","journal-title":"Eur Heart J"},{"key":"B16","doi-asserted-by":"publisher","first-page":"1532","DOI":"10.1111\/pace.14336","article-title":"Is His-optimized superior to conventional cardiac resynchronization therapy in improving heart failure? Results from a propensity-matched study","volume":"44","author":"Senes","year":"2021","journal-title":"Pacing Clin Electrophysiol"},{"key":"B17","doi-asserted-by":"publisher","first-page":"1447","DOI":"10.1093\/oxfordjournals.eurheartj.a060084","article-title":"Exercise dependent complete left bundle branch block","volume":"13","author":"Hertzeanu","year":"1992","journal-title":"Eur Heart J"},{"key":"B18","first-page":"1326","article-title":"Simultaneous appearance of precordial pain and effort-induced left bundle branch block. A study of 6 patients with normal coronary angiography","volume":"78","author":"Bory","year":"1985","journal-title":"Arch Mal Coeur Vaiss"},{"key":"B19","doi-asserted-by":"publisher","first-page":"474","DOI":"10.1016\/S0300-8932(02)76596-2","article-title":"Exercise-induced left bundle-branch block in patients with coronary artery disease versus patients with normal coronary arteries","volume":"55","author":"Candell Riera","year":"2002","journal-title":"Rev Esp Cardiol"},{"key":"B20","doi-asserted-by":"publisher","first-page":"1883","DOI":"10.1093\/eurheartj\/ehy037","article-title":"2018 ESC Guidelines for the diagnosis and management of syncope","volume":"39","author":"Brignole","year":"2018","journal-title":"Eur Heart J"},{"key":"B21","doi-asserted-by":"publisher","first-page":"2473","DOI":"10.1093\/eurheartj\/ehad322","article-title":"Short-duration head-up tilt test potentiated with sublingual nitroglycerin in suspected vasovagal syncope: the fast Italian protocol","volume":"44","author":"Russo","year":"2023","journal-title":"Eur Heart J"},{"key":"B22","doi-asserted-by":"publisher","first-page":"e60","DOI":"10.1161\/CIR.0000000000000499","article-title":"2017 ACC\/AHA\/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society","volume":"136","author":"Shen","year":"2017","journal-title":"Circulation"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2024.1438320\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,1,8]],"date-time":"2025-01-08T06:16:40Z","timestamp":1736317000000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2024.1438320\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1,8]]},"references-count":22,"alternative-id":["10.3389\/fcvm.2024.1438320"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2024.1438320","relation":{},"ISSN":["2297-055X"],"issn-type":[{"type":"electronic","value":"2297-055X"}],"subject":[],"published":{"date-parts":[[2025,1,8]]},"article-number":"1438320"}}