心尖肥厚型心肌病的临床诊断(附13例临床报告)

目的：探讨心尖肥厚型心肌病的心电及影像学检查的特点及临床诊断价值。方法：对13例心尖肥厚型心肌病的心电图、超声心动图、放射核素心肌断层显像、冠状动脉造影及左室造影、磁共振成像等检查方法进行分析总结。结果：心电图的典型改变是胸前导联巨大倒置的T波伴ST段下降和QRS波群高血压,以V4导联最为显。超声心动图示心尖部肥厚,心尖部心室腔狭小甚至闭塞。磁共振成像清晰显示心尖部心肌肥厚。心室造影左心室舒张末期呈“黑桃”样改变,但部分呈“非黑桃”样改变。结论：心电图胸前导联巨大倒置T波TV4＞TV5伴QRS波群高血压RV4＞RV5是诊断AHCM的重要线索。超声心动图是诊断AHCM的重要手段。磁共振成像对确诊该病最有价值。心血管造影及放射性核素心肌显像是AHCM的鉴别诊断手段但不是必备检查。     

心尖肥厚型心肌病临床诊断探讨(附18例临床报告)

以心电图、超声心动图、放射核素心肌断层显像（99mTC－MIBI）、冠状动脉造影及左心室造影等检查方法，诊断18例心尖肥厚型心肌病。18例心电图显示胸导联倒置的T波呈TV4＞TV5TV5＞DV6的关系。超声心动图左心室心尖部（乳头肌水平以下）心肌肥厚，达12mm以上。8例行放射核素心肌断层显像见左心室心尖部心肌肥厚。10例左心室造影均提示心尖部心肌肥厚，其中6例左心室舒张末期呈"黑桃"样改变，冠状动脉造影正常。此文就18例心尖肥厚型心肌病的临床诊断进行探讨。     

心尖肥厚型心肌病18例临床分析

目的:对心尖肥厚型心肌病辅助检查进行分析,探讨其临床诊断价值。方法:以心电图、超声心动图、磁共振、冠状动脉造影及左室造影等检查方法检测18例心尖肥厚型心肌病。结果:18例心电图显示胸前导联T波倒置呈TV4>TV5>TV3,R波振幅增高以RV4>RV3> RV5;超声心动图左室心尖室壁舒张期厚度(17.22±14.20mm)与心室间隔基底段厚度(1.07±0.23mm)之比为1.60±0.16;4例冠状动脉造影检查后排除冠心病;6例因超声心动图不典型而行磁共振心脏成像检查后确诊。结论:标准12导联心电图显示胸前导联T波倒置伴R波增高应高度怀疑心尖肥厚型心肌病,可进一步行超声心动图或磁共振检查确诊。     

50例心尖肥厚型心肌病患者心电图特点分析

对2002～2006年确诊的50例心尖肥厚型心肌病(AHCM)患者的心电图进行回顾性分析,结果发现50例患者均有左胸导联T波倒置及ST段压低,呈典型的Tv4＞Tv5＞Tv3者30例,左胸导联R波电压增高44例,Rv4＞Rv5＞Rv6者35例.认为胸前导联T波倒置伴R波振幅增高为AHCM的特征性心电图表现,临床应注意与冠心病、心肌梗死等鉴别.     

左心室心尖部室壁增厚特征与心电图T波倒置关系分析

目的:探讨左心室心尖部室壁增厚且心电图胸前导联出现无法解释的广泛T波倒置患者的室壁增厚特征与心电图T波倒置的关系。方法:连续入选91例超声心动图提示左心室心尖部室壁增厚且心电图胸前导联广泛T波倒置的患者,包括53例典型心尖肥厚型心肌病(AHCM)患者(典型AHCM组)、25例早期AHCM患者(早期AHCM组)、13例可疑AHCM患者(可疑AHCM组)。在典型AHCM组与早期AHCM组中共有单纯型29例,混合型49例。测量各导联T波倒置的深度(T)及T波倒置的最大深度(Tmax),测量心尖部各室壁厚度及最大厚度(APWTmax)并计算其与左心室后壁厚度的比值(ABR)。结果:各组间心电图上T波倒置的导联分布、最大深度及胸前导联T波倒置的深度之和比较差异无统计学意义。在78例典型和早期AHCM患者中,心尖厚度与T波深度无明显相关性,但在其中的29例单纯型患者中,APWT max分别与TV_5(r=0.381)及Tmax(r=0.416)弱相关;而在49例混合型及13例可疑AHCM患者中心尖厚度与T波深度也无明显相关。结论:在左心室心尖肥厚程度与T波深度关系上,只有单纯型AHCM患者的APWTmax与T波深度弱相关,而在混合型AHCM患者中二者无明显相关性。     

胸导联T波直立的急性心肌梗死临床分析

目的 分析心电图貌似正常的急性心肌梗死患者的胸导联特征,以及对梗死相关动脉（IRA）的判断价值。方法 回顾2018年1月至2019年12月急诊心电图貌似正常、冠脉造影诊断明确为急性心肌梗死患者的心电图资料,分析胸导联T波和QRS波特点。结果 10例患者经冠脉造影明确IRA为前降支（LAD）7例,回旋支（LCX）3例,心电图均显示胸导联T波直立,所有患者均TV2/TV6比值>1。IRA为LAD者经皮冠状动脉介入术后心电图均变为Wellens综合征II型改变,而IRA为LCX者均无明显变化。RV3和RV2/SV2比值LCX组高于LAD组（p=0.03和0.02）。RV3≥0.7mV者4例,其中3例IRA为LCX(1例为LAD者测值为0.7mV);RV2/SV2比值≥0.7者3例,其IRA均为LCX。结论 对有典型心绞痛样持续性胸痛、胸闷症状而心电图貌似正常者,需关注胸导联T波形态和右胸导联R波振幅,有助于急性心肌梗死的早期诊断和及时再灌注治疗。     

肥厚性心肌病心尖肥厚亚型的临床诊断(附28例临床报告)

目的对心尖肥厚型心肌病的辅助诊断进行探讨。方法以心电图、超声心动图、放射核素心肌断层显像、冠状动脉造影及左室造影等检查方法，诊断２８例心尖肥厚型心肌病。结果２８例心电图显示胸导联倒置的Ｔ波呈ＴＶ４＞ＴＶ５的关系；超声心动图左室心尖部（乳头肌水平以下）心肌肥厚达１２ｍｍ以上；１８例行放射核素心肌断层显像见左心室心尖部心肌肥厚；２０例左心室造影均提示心尖部心肌肥厚、冠脉造影正常，其中１１例左心室舒张末期呈“黑桃”样改变。结论标准１２导联心电图显示胸导联倒置的Ｔ波伴Ｒ波振幅增高，而不伴有高血压病史者，应高度注意心尖肥厚型心肌病的诊断。     

巨大倒置T波对心尖部肥厚型心肌病临床诊断的探讨

目的 :探讨心尖部肥厚型心肌病 (AHCM)所呈现的巨大倒置 T波对其诊断的价值。方法 :回顾性分析 1976～ 1999年间收治的 10例 AHCM患者的临床资料 ,并与同期 32例非 AHCM进行比较。结果 :AH CM心电图呈现胸导联 V3～ 5巨大倒置 T波 ,且以 V4导联最为显著 ,特异性可高达 10 0 %。结论 :正中胸导联巨大倒置 T波对 AHCM临床初诊及筛选具有一定的实用价值     

心电图对肥厚型心肌病的诊断价值

目的通过回顾分析心尖肥厚型心肌病(AHCM)患者的12导联心电图特点,探讨其对AHCM的诊断指导价值。方法对2014年12月~2016年12月于河南省安阳地区医院心内科就诊的60例AHCM患者作为观察组,与同时期我院正常体检人群50名为对照组。行12导联心电图,进行回顾性分析,比较两组人群的心电图变化情况及有无特征性变化等。结果观察组患者心电图表现为胸导联T波倒置伴ST段下移及左室高电压表现;胸导联QRS波群时间延长,且QRS波群振幅在不同导联上变化明显,均超过正常值;在ST段分别表现为V3~V6和Ⅱ、Ⅲ、a VF下移;且有42例出现V3~V6 T波倒置。患者左胸导联R波电压增高,ST段压低,0.05m V,T波对称性倒置,左胸导联同导联R波高度与T波倒置深度,ST段压低深度呈负相关(P0.05),T波倒置深度与ST段压低深度呈正相关(P均0.01)。结论心电图诊断对心尖肥厚型心肌病有辅助指导价值,对AHCM患者早期行心电图检查可提高其疾病确诊率。     

心尖肥厚型心肌病1例

患者,男,60岁,因发作性胸闷、气短半月就医,心电图示STV3～V6显著下移0.1～0.2my,胸前导联T波深倒,酷似"冠状T波"且TV4(13 mm)＞T V5(11 mm) ＞TV3(9 mm),同时R波增高RV4＞RV5＞RV3,Ⅰ、aVL、Ⅱ、aVF导联T波倒置,Ⅲ导联T波(+、-)双向,aVR直立,心电图诊断:ST-T变化.临床诊断为冠心病,给予相应治疗.1个月后患者步行来院复诊,心电图示ST-T改变与第1次就诊大致相同,倒置的T波明显变浅,但患者的临床症状并无好转.半个月后,患者感觉乏力、多次发生晕厥,有胸痛症状,自服硝酸甘油治疗无效,再次来院就诊,心电图示ST-T改变与前两次基本相同,心率明显增快,倒置的T波变浅.患者无糖尿病、高血压病史.冠状动脉造影:左右冠状动脉显影良好,无狭窄现象.心脏超声示左室流出道无梗阻,二尖瓣无反流,心室腔内径正常,心尖部室间隔和左室后下壁明显增厚,增厚的心肌回声紊乱、粗糙.临床诊断为心尖肥厚型心肌病.     

心尖肥厚型心肌病的临床诊断探讨

目的 了解心尖肥厚型心肌病的临床表现和辅助检查特点。方法 总结２９例心尖肥厚型心肌病的临床表现和心电图,超声心动图,核素心肌断层显像,运动平板心电图及冠状动脉和左室造影的特征,确定心尖肥厚型心肌病的诊断方法。结果 心电图显示以胸导为主的导联Ｒ波振幅呈Ｖ４≥Ｖ５〉Ｖ３关系增高,同时伴有Ｔ波对称性深倒置,超声心动图和核素心肌断层显像显示心尖部肌肉肥厚,２０例活动平板心电图有心肌缺血,左心室造影心尖部肌     

Crochetage R波切迹在房间隔缺损诊断中的应用价值

目的：探讨心电图下壁导联的R波切迹诊断房间隔缺损（ASD）的价值。方法：分析19例ASD心电图（ASD组）,19例正常人作为对照组（正常对照组）的心电图资料。ASD的诊断均经超声心动图证实,并未行手术矫正。结果：19例ASD心电图中,下壁导联出现R波切迹者18例（94.7%）;正常对照组有3例（15.8%）出现R波切迹,ASD组心电图下壁导联出现R波切迹的比率显著高于正常人组（94.7%vs15.8%,P〈0.0001）。以心电图下壁导联出现R波切迹诊断ASD的敏感性,特异性,准确性分别为94.7%和88.9%,89.5%。结论：心电图下壁导联R波切迹是诊断ASD的一项有价值的,新的指标。     

S-T segment depression in right-sided precordial leads during acute inferior wall infarction.

Right-sided chest leads (V3-V4R) were recorded in the early stages of first inferior wall acute myocardial infarction (AMI) in 100 consecutive patients. Nine patients (9%) presenting with S-T segment depression (greater than 1 mm) in these leads were subsequently studied by echocardiography and radionuclear angiography. In this group, there were 5 patients with intact right ventricular (RV) function and 4 other patients with clinical findings compatible with RV infarction. We suggest that one should not rule out RV involvement when S-T segment depression rather than elevation is seen in the right precordial leads in the presence of inferior wall AMI. An individual assessment for RV infarction is recommended when this pattern is apparent on the ECG.     

心尖肥厚型心肌病与典型肥厚型心肌病的临床特点比较

目的 通过与典型的肥厚型心肌病(HCM)比较,探讨中国汉族人心尖肥厚型心肌病(AHCM)的临床特征及其诊治方法.方法 回顾性收集160例HCM住院患者的临床资料,分成3组进行比较.AHCM组:AHCM 41例.典型HCM患者(室间隔以及左心室壁肥厚),根据是否存在流出道梗阻分成2组,即非梗阻性肥厚型心肌病(NOHCM)组,52例,左心室流出道压差＜30 mm Hg(1 mm Hg=0.133 kPa);梗阻性肥厚型心肌病(OHCM)组,67例,左心室流出道压差≥30mm Hg.比较3组患者的临床症状、诊治方法以及血浆生物标记物水平.结果 (1)AHCM组患者的发病年龄较OHCM组晚[(49.9±13.6)岁比(41.4±14.6)岁,P＜0.01],无猝死家族史,较少出现劳力性呼吸困难,血浆血N末端B型利钠肽原(NT-pro BNP)水平较OHCM组低(P＜0.01).血浆心肌酶中肌酸激酶同工酶(CK-MB)、乳酸脱氢酶(LDH)、肌钙蛋白I(TnI)和肌红蛋白(MYO)的水平在3组间差异均无统计学意义.(2)31例AHCM患者因冠心病收治入院,经检查后,18例(18/41,43.9%)排除了冠心病.(3)AHCM组、NOHCM组和OHCM组心电图上深尖倒置T波(GNT)出现的频率分别为43.9%、13.5%和4.4%(P＜0.01),且AHCM组多伴有左心室高电压.(4)心脏核磁共振诊断AHCM明显优于心脏超声,与诊断典型HCM相比更有优势.结论 AHCM与典型OHCM的临床特点比较差异有统计学意义,而与典型的NOHCM比较差异无统计学意义.心脏核磁共振检查阳性及心电图胸导联上典型的GNT可为确诊AHCM提供依据.

Abstract：

Objective To evaluate the clinical features in Chinese patients with apical hypertrophic cardiomyopathy (AHCM) and typical hypertrophic cardiomyopathy (HCM). Methods This retrospective analysis included 160 patients hospitalized in Fuwai hospital. Patients were divided into three groups: apical hypertrophic cardiomyopathy ( AHCM, n = 41 ) group, non-obstructive typical hypertrophic cardiomyopathy group[NOHCM, LVOT ＜30 mm Hg(1 mm Hg =0. 133 kPa) at rest, n =52] and obstructive typical hypertrophic cardiomyopathy (OHCM, LVOT ≥ 30 mm Hg at rest, n = 67). Clinical features, diagnosis,therapy, and plasma levels of biomarkers of these three groups were analyzed. Results ( 1 ) The age at disease onset was older in AHCM group than in OHCM group [(49. 9 + 13. 6) years vs. (41.4± 14. 6)years, P ＜ 0. 01]. Exertional dyspnea appered more often in HCM patients than in AHCM patients, NT-proBNP level was significantly lower in AHCM patients than in OHCM patients (P =0. 001 ). Plasma CK-MB, LDH, TnI and MYO levels were similar among the three groups. (2) Thirty-three AHCM patients were first hospitalized for suspected coronary heart disease (CHD) and CHD was excluded in 18 cases (43.9%).(3) The frequency of giant negative T waves (depth≥10 mm) on ECG was 43.9%, 13.5% and 4.4%(P ＜ 0. 01 ) in AHCM, NOHCM and OHCM respectively. Half of AHCM patients showed left ventricular high voltage on ECG. (4) Cardiac magnetic resonance imaging is superior to echocardiography on correctly diagnosing AHCM. Conclusion AHCM patients differ from typical OHCM patients in clinical characteristics. There were significant differences on echocardiography and electrocardiography features among three groups. Cardiac magnetic resonance imaging and giant negative T waves on ECG are helpful for the diagnosis of AHCM.     

Ⅱ、Ⅲ、aVF导联R波切迹诊断房间隔缺损的探讨

目的探讨心电图Ⅱ、Ⅲ、aVF导联R波切迹对检出房间隔缺损(ASD)的意义。方法分析74例ASD心电图,74名正常人作为对照组。ASD的诊断均经超声心动图证实和未予手术矫正。结果 74例ASD心电图中,Ⅱ、Ⅲ、aVF导联出现R波切迹者44例(59.5%),其中8例(10.8%)于Ⅱ、Ⅲ、aVF导联中的一个导联出现R波切迹,16例(21.6%)两个导联出现R波切迹,20例(27.6%)三个导联同时出现R波切迹。正常人组中仅7例)9.4%)在Ⅱ、Ⅲ、aVF导联中出现R波切迹,一个导联、两个导联及三个导联出现R波切迹的例数分别为3例(4.0%)、2例(2.7%)和2例(2.7%)。ASD组心电图Ⅱ、Ⅲ、aVF导联出现R波切迹比率显著高于正常人组(59.5%vs.9.4%,p<0.005)。以心电图Ⅱ、Ⅲ、aVF导联出现R波切迹诊断ASD的敏感性和特异性分别为59.5%和90.5%。结论心电图Ⅱ、Ⅲ、aVF导联R波切迹是心电图诊断ASD的一项指标。     

心尖肥厚型心肌病53例临床分析

目的:探讨心尖肥厚型心肌病(AHCM)的临床表现、心电图特点、冠状动脉造影(CAG)结果和长期预后情况。方法:对53例经超声心动图确诊的AHCM患者,进行病史回顾、体格检查、心电图和CAG检查,并通过电话和门诊随访,了解心血管事件发生情况。结果:AHCM患者病史不典型,但心电图有特征性变化,表现为胸前导联巨大倒置T波,尤其以V4导联显著,伴有ST段下移,常被误诊为冠心病。30例行CAG者中28例示左冠状动脉明显增粗;3例发现器质性狭窄,并成功置入支架;7例发现心肌桥,均位于左前降支。经0·4~7·5年的随访,仅1例死于癌症。结论:AHCM有比较典型的心电图表现,左冠状动脉内径增粗,常并发肌桥和冠心病,远期预后较好。     

Long-term evaluation of patients with apical hypertrophic cardiomyopathy: Correlation between quantitative echocardiographic assessment of apical hypertrophy and clinical-electrocardiographic findings

Apical hypertrophic cardiomyopathy (AHCM) is characterized byprimary hypertrophy localized exclusively in the apex of theleft ventricle. Previous studies have indicated that AHCM resultsin a unique combination of cross-sectional echocardiographic(CSE) and ECG findings (‘giant’ Twave inversionand high R wave voltage in the precordial leads). The aims ofthis study were: (1) to assess the degree of AHCM in a quantitativefashion (2) to evaluate the possible relationship between apicalhypertrophy, quantitatively determined, and ECG findings inpatients with AHCM (3) to verify the changes in echocardiographicand ECG parameters over time (4) to define the relationshipbetween the severity of AHCM and the clinical course of suchpatients. Eleven selected patients with AHCM were studied for an average6 year follow-up period; there were seven men and four women(age from 18 to 62 years, mean 49). Apical hypertrophy was assessedquantitatively by determining the muscle cross-sectional areain the apical region, which was considered an index of myocardialmass. From the end-diastolic apical four chamber view, endocardialand epicardial contours were digitized in order to obtain thetotal muscle cross-sectional area of the left ventricle. Thewalls of the left ventricle were then divided into three regions(basal, intermediate, apical). The final value of each cross-sectionalmuscle area was obtained from the mean measurements of fourindependent and blinded observers. In AHCM the apical musclecross-sectional area (AMA) ranged from 10.3 to 17.9 cm², mean13.2 ±2.6 cm². The comparison between CSE and ECG findingsshowed that patients with giant negative T wave inversions (Twave >10 mm) and high R wave voltages (R wave >25 mm)had a more severe degree of apical hypertrophy. However, therewas incomplete agreement between CSE and ECG findings. During follow-up, negative T wave amplitude increased from 8.5±3.4 to 11.9 ±3.6 mm (mean 4.2 ±2.7) in10 patients (P>0.01) and there was a mild increase of precordialR wave (from 28.0 ±5.9 to 29.3 ± 5.2 mm, mean1.5 ± 1.6) (P–ns). The AMA change over time, from13.2 ± 26 to 13.8 ± 2.3 was not significant. Allpatients were alive at the most recent evaluation, and witlioutsignificant symptomatic deterioration. This study demonstrates a wide spectrum in the degree of severityof apical hypertrophy among patients with AHCM. Furthermore,ECG findings are not uniform and are not significantly relatedto the severity of the hypertrophy itself Therefore, AHCM shouldbe considered as a part of the morphological spectrum of hypertrophiccardiomyopathy rather than a separate entity with univocal CSEand ECG findings. Follow-up data indicate that despite ECG results worsening overtime, a significant progression in apical left ventricular wallthickness does not occur. Changes in negative T wave amplitudeare not related to symptoms and are not predictive of the functionalseverity of AHCM. Finally, the clinical outcome of patientswith AHCM seems not be dependent on the entity of apical hypertrophy.     

Clinical significance of changes in electrocardiographic R-wave voltage on chest leads in patients with acute anterior myocardial infarction

This article aims to clarify the clinical significance of changes in electrocardiographic (ECG) R-wave voltage on chest leads from 1 to 4 weeks in patients with acute anterior myocardial infarction (MI) in combination with echocardiographic findings and dual scintigraphic findings. Seventy-one patients with acute anterior MI who underwent emergency revascularization were subjected to ECG and echocardiography, at both 1 and 4 weeks, and to thallium-201 (TI) and iodine-123-beta-methyl-p-iodophenyl pentadecanoic acid (BMIPP) single-photon emission computed tomography (SPECT) about 1 week after the onset of MI. The total sum of ECG R-wave voltage on each chest lead was calculated. The mean defect ratio on TI and that on BMIPP derived from circumferential profile curve analysis were calculated. The percentage defect-discordant ratio of both SPECT images [(%) discordance on TI/BMIPP] was obtained. The percentage increase ratio of ECG R-wave voltage on chest leads [(%) increase of R wave] and the increase of left ventricular ejection fraction (DeltaEF) from 1 to 4 weeks were obtained. There were significant correlations between the (%) increase of R wave and the DeltaEF as well as between the (%) increase of R wave and the (%) discordance on TI/BMIPP (r =.63, P <.001; r =.74, P <.001). The reversibility of ECG R-wave voltage was related to cardiac functional improvement in addition to the discordance on the 2 images. Monitoring of changes in ECG R-wave voltage on chest leads is useful to detect the presence of myocardial viability and to evaluate functional evolution in patients with acute anterior MI.     

ECG manifestations in submassive and massive pulmonary embolism. Report of 4 cases and review of literature

ECG findings suggestive of right ventricular (RV) hemodynamic derangement, in the appropriate clinical setting, can lead to further diagnostic consideration and earlier institution of treatment, aiming to decrease the high morbidity and mortality associated with submassive and massive pulmonary embolism (PE). In this paper, we review 4 cases with chest computed tomography (CT) confirmed PE with their respective ECG findings. In all the cases patients had an RV strain pattern on ECG, although in different clinical scenarios, including one with an initial diagnosis of acute coronary syndrome (ACS). In one case, a transitory short PR interval was seen, a finding not previously reported, in the literature. The most common finding was T wave inversion (Twi) in the anterior leads.     

Value of the surface electrocardiogram in detecting right ventricular dilatation in the presence of left bundle branch block

Approximately 20% of patients with heart failure have left bundle branch block (LBBB) on surface electrocardiogram (ECG). In this group of patients, detection of right ventricular (RV) dilatation on standard ECG can be of clinical relevance because RV enlargement is an important prognostic marker. Consequently, the aim of this study was to evaluate diagnostic accuracy for several electrocardiographic criteria in determining significant RV dilatation in these patients. Standard 12-lead ECGs were obtained in 173 patients with heart failure and known LBBB. From the ECG, 3 criteria for RV dilatation were defined: presence of terminal positivity in lead aVR (late R wave in lead aVR), low voltage (<0.6 mV) in all extremity leads, and an R/S ratio <1 in lead V(5). In addition, all patients underwent comprehensive echocardiographic evaluation including assessment of RV dimensions. Measurements were performed blinded to electrocardiographic results. Significant RV dilatation was defined as an RV base-to-apex length ≥ 86 mm or an RV diastolic area ≥ 33 cm(2). Eighty-six patients (50%) had a late R wave in lead aVR, 36 patients (21%) had low voltage in extremity leads, and 67 patients (39%) had an R/S ratio <1 in lead V(5). An RV base-to-apex length ≥ 86 mm was present in 67 patients (39%), and 62 patients (36%) had an RV diastolic area ≥ 33 cm(2). Any combination of 2 to 3 positive criteria could predict an RV base-to-apex length ≥ 86 mm with a positive predictive value of 89% and a negative predictive value of 88%. Similarly, an RV diastolic area ≥ 33 cm(2) was predicted with a positive predictive value of 80% and a negative predictive value of 88%. In conclusion, combining 2 to 3 distinct electrocardiographic criteria allows for accurate detection of RV dilatation in patients with heart failure and LBBB.