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Case Reports
. 2018 Jul 23;2(3):yty085.
doi: 10.1093/ehjcr/yty085. eCollection 2018 Sep.

Case report: Posterior myocardial infarction in presence of right bundle branch block: an old concept with new findings

José Antonio Cornejo-Guerra  1 , Daniel Manzur-Sandoval  1 , José Fernando Guadalajara-Boo  2 , José Luis Briseño-de la Cruz  3
Affiliations
Case Reports

Case report: Posterior myocardial infarction in presence of right bundle branch block: an old concept with new findings

José Antonio Cornejo-Guerra et al. Eur Heart J Case Rep. .

Abstract

Background: The diagnosis of acute ischaemic coronary syndromes in presence of an intra-ventricular conduction disturbance represents a clinical challenge. In the cardiac segmentation model the posterior wall is replaced by the basal inferior segment. However, in the clinical scenario of acute coronary syndrome the concept of posterior myocardial infarction (PMI) endures. The association of a PMI and right bundle branch block (RBBB) is a rare condition characterised by broad R waves and ventricular repolarization disorders in right precordial leads in both entities, which could lead to misinterpretation and delay in reperfusion therapy.

Case summary: We describe a case report of a 74-year-old man with acute chest pain and an electrocardiogram with broad R waves, a 4 mm ST-segment downsloping (excessively discordant) in right precordial leads, RBBB, and ST-segment elevation in posterior leads. There was resolution of ST-segment downsloping in right precordial leads after percutaneous coronary intervention and stenting of the circumflex artery, with disturbance of the repolarization process only attributable to RBBB.

Discussion: Patients with acute chest pain with RBBB and a ST segment with an excessive downsloping (out of proportion of what is expected in isolated RBBB) suggest PMI with occlusion of the circumflex coronary artery.

Keywords: Bundle branch block; Case report; Posterior myocardial infarction; Right bundle branch block.

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Figures

Figure 1
Figure 1
A 12 lead electrocardiogram at patient admission.
Figure 2
Figure 2
Coronary angiography pre- and post-percutaneous coronary intervention.
Figura 3
Figura 3
Electrocardiograms performed immediately and at 48 h after successful percutaneous coronary intervention.
Figure 4
Figure 4
(A) The process of ventricular depolarization in the presence of right bundle branch block. (B) The process of ventricular repolarization in the presence of right bundle branch block. Reproduced from de Micheli et al.
Figure 5
Figure 5
The vector of the ‘injured area’ points towards the infarction, with ST-segment depression in V1–V2 and ST-segment elevation in posterior leads (V7–V9). Reproduced from Castellano et al.
See this image and copyright information in PMC

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