![]() He underwent primary percutaneous coronary intervention (PCI) of the proximal left anterior descending coronary artery (LAD). He was rated Killips Class 1 (no evidence of congestive heart failure), TIMI risk score 4 (14% risk of all-cause 30-day mortality). Hospital Course He was diagnosed with anterior wall STEMI and taken to the cath lab. He had a history of hypertension, 40 pack-year smoker. The Patient This ECG was obtained from a 51-year-old man who presented to EMS with acute chest pain. Read more about Right Bundle Branch Block With Probable Previous M.I.The J points in this ECG all appear to be at the baseline, with no overt STEMI. Occasionally, the terminal delay – especially in Leads III and aVF – can be mistaken for ST elevation. Right bundle branch block can make evaluating for ST segment elevation a bit tricky. It would, of course, help to know this patient’s history. that would have caused these Q waves is old, as there are no acute ST changes. However, the probability of pathological Q waves in the inferior leads offers a more likely explanation for the leftward axis shift. Lead II will be very small, or flat, or negative. LAH causes a frontal plane axis shift – instead of Lead II having the tallest QRS of the limb leads, Leads I and aVL will be the tallest upright QRS complexes of the six limb leads. The left anterior fascicle has the same blood supply as the right bundle branch. It is not unusual for people with RBBB to also have a left anterior hemiblock (LAH), also called left anterior fascicular block. It is normal for the T waves to be in a direction opposite that of the terminal wave (inverted in Leads V 1 and III, for example.) This delay can be seen in every lead, but is especially easy to see in Leads I and V 6, where there is a wide little s wave. This terminal delay widens the QRS without affecting the depolarization or contraction of the left ventricle. The R prime (R’) represents the right ventricle depolarizing slightly after the left ventricle. The QRS is wide at 148 ms (.148 seconds). We see the right bundle branch block (RBBB) pattern: rSR’ in the right precordial leads (with a tiny q wave in V1, which is not typical of RBBB). There is a first-degree AV block, with a PR interval of 232 ms. This is a good opportunity to teach the value of evaluating rhythm strips in more than one simultaneous lead, as subtle features may not show up well in all leads. We suggest Lead I to best view the P waves in this example. The P waves are small, and difficult to see. ![]() So, it is normal sinus rhythm, but the rate is probably not “normal” for this patient. We have no other clinical information.ĮCG Interpretation The rhythm is regular and fast, with P waves, at 95 beats per minute. This ECG was obtained from an 87-year-old man with chest discomfort.
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