STEMI in Right Bundle Branch Block

Vignette:  A 60 yo with h/o of DM and HTN is c/o chest pain. 

The 12L shows sinus rhythm at about 80 bpm with right bundle branch  block (RBBB) pattern. There are ST elevations in all precordial leads (V1-V6), I and aVL. There are ST depressions in III and aVF. This is anterior wall STEMI. Angiography showed lesion in the proximal LAD and intervention was done.

Group-beating: footprints of a Wenckebach

What is your ECG interpretation?

Figure 1-  ECG case

A 2:1 is not Mobitz II

Vignette: A 70 yo is admitted due to dizziness. What is your ECG interpretation?

Figure 1 - ECG case

The rhythm is sinus with an atrial rate of about 65 bpm and the ventricular rate of about 34 bpm. The PRI is 0.28 s and the QRS is 0.12 sec. There are 2 P wave for every 1 QRS (Figure 2).

Figure 2 - P waves marked with red arrows

Something wrong with this block

 A 65 yo with h/o HTN, CAD, S/P CABG c/o chest pain.

Figure 1 - ECG case

This is sinus bradycardia with right bundle branch block (RBBB) pattern in the precordial leads  (predominant R waves in V1). However, the T waves are upright in V2 and V3 and  not as inverted in V1. Typical RBBB pattern had T waves that are opposite in direction to the R waves.

Cardiac catheterization was done. It revealed a depressed LV systolic function (EF ~ 30%) with patent vein grafts to the right coronary artery and left anterior descending artery. Revascularization of the native AV groove circumflex artery with stent.

Figure 2 - post- cardiac catheterization ECG

The  ECG showed sinus rhythm with RBBB pattern but now the T waves are inverted in V1-V3.

So, this case is RBBB in the setting of a circumflex artery lesion.

Here is another article 

#634

Hyperkalemia + RBBB

This is the 12L ECG of a 70 yo patient with h/o of HTN, hyperlipidemia DM, CHF and ESRD c/o vomiting.

Figure 1

The 12L showed a regular wide QRS rhythm at rate of about 94 bpm, RBBB morphology and left anterior fascicular block pattern. P waves are best seen in long lead II. The QRS duration is about 200 ms which is very wide. Tall and tented T waves can be appreciated in V3. This ECG is highly suggestive of an ECG pattern of a patient with hyperkalemia.

Potassium came back at 6.5. Calcium gluconate, glucose/insulin and sodium bicarbonate were given and was dialyzed.

Interpretation: Sinus rhythm, right bundle branch block, left anterior fascicular block, hyperkalemia. 

#632

Sinus rhythm with long PRI mimicking junctional rhythm

Vignette: Elderly patient with history of chronic smoking, DM, HTN and dyslipidemia was brought in due to  weakness and fall. Patient is being worked-up for possible CVA.

What is the rhythm?

Image 1

This is a regular, wide QRS complex rhythm with left anterior fascicular block (LAFB) and right bundle branch block (RBBB). Our differential are: junctional rhythm or a SR with a long PR interval with P hidden from view as it merges with the T wave. 

Image 2

The rhythm strip revealed the P waves and the long PR interval.

Going back to the 12 lead, if you look closely in lead II you see distortions at the descending portion of the T waves.

For the case, it was found that it was indeed stroke. Managed as that and later sent for rehab and risk factors addressed.

#142