SummaryRoutine pre-operative evaluation of a 58-year-old man scheduled for repair of an inguinal hernia, disclosed a blood pressure of 200/100 mmHg. This decreased to 150/100 mmHg after a period of rest. An electrocardiogram taken as a result of this chance finding showed left bundle branch block. There were no other cardiovascular symptoms or signs. Soon after induction of general anaesthesia, the conduction defect disappeared. The return to sinus rhythm was sudden and sustained and was not related to changes in heart rate or blood pressure. One month later, his electrocardiograph remained normal. Intermittent left bundle branch block is uncommon and its development during anaesthesia more so [1, 2]. It must be distinguished from the more common intermittent bundle branch block, where both normal and abnormal complexes are seen in the same electrocardiogram (ECG) record. Although there are a number of causes of right bundle branch block, left bundle branch block (LBBB) is most frequently associated with ischaemic heart disease [3, 4]. Particular care is needed when anaesthetising patients who have LBBB. They should be managed with the same delicacy as patients who have significant ischaemic heart disease.We present a case of a patient in whom LBBB, an incidental finding during pre-operative screening, reverted to sinus rhythm during anaesthesia. Because myocardial ischaemia is unlikely to lessen during anaesthesia, an asymptomatic patient whose ECG shows LBBB represents a significant dilemma for the anaesthetist. Case historyA 70-kg, 58-year-old Caucasian male, with a body mass index of 23.1, was scheduled for repair of right inguinal hernia under general anaesthesia. Pre-assessment disclosed only a history of a single episode of fainting many years before. Clinical examination was unremarkable. He did not receive any medication and had no known allergies.On admission, the patient's blood pressure was found to be elevated at 200/100 mmHg. This settled within a few hours but he remained mildly hypertensive with a blood pressure of 150/100 mmHg. His pulse rate was 90 beat. min ÿ 1 . Re-examination showed all pulses were normal, that the apex beat was not displaced and heart sounds were normal. There was no evidence of congestive heart failure. A chest X-ray was reported normal. His routine biochemical and haematological tests were within the normal limits. An ECG, obtained because of the chance finding of hypertension, showed normal sinus rhythm with a heart rate of 85 beat.min ÿ 1 and LBBB (Fig. 1). Following reassessment, no further investigations were considered appropriate or necessary because the patient gave no history suggestive of ischaemic heart disease and had an excellent exercise tolerance.He received no premedication. Before induction of anaesthesia, routine monitors (electrocardiography (CM5), oxygen saturation and noninvasive blood pressure) were placed and baseline observations made. He was preoxygenated with 100% oxygen. Anaesthesia was induced 684ᮊ 1997 Blackwell Science Ltd with thiopentone 40...

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