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Case Reports
. 2021 Feb 11;13(2):e13281.
doi: 10.7759/cureus.13281.

ECG Changes in a Case of Posterior Myocardial Infarction in the Presence of Right Bundle Branch Block

Aliya Ramjaun  1 , Ankit Garg  2 , Marlee Klaiman  1 , Matthew Sibbald  2 , Junghwan Kevin Dong  1
Affiliations
Case Reports

ECG Changes in a Case of Posterior Myocardial Infarction in the Presence of Right Bundle Branch Block

Aliya Ramjaun et al. Cureus. .

Abstract

A 70-year-old male with hypertension and diabetes presented to the emergency department with a 1-hour history of chest pain. Initial 12-lead ECG revealed a right bundle branch block (RBBB) and ST depression (STD) in V2-V4. The anterior STD prompted a 15-lead ECG in which there was no evidence of ST elevation (STE). With a positive troponin, cardiology was consulted and the patient was admitted as a high-risk non-ST-elevation myocardial infarction (NSTEMI). Subsequently, his chest pain returned without further ST changes, regardless the patient went for emergency coronary angiography, which found a complete occlusion of the left circumflex artery. Anterior STD is a normal finding in RBBB and posterior STEs in the posterior leads are not always present making the recognition of posterior STEMI difficult. This case highlights three findings in leads V1-V3 that are concerning for posterior ischemia in the context of chest pain and an RBBB: tall R waves, upright T waves, and marked STD > 2 mm. This should prompt serial 15-lead ECGs and prompt cardiology consultation.

Keywords: cardiac electrophysiology; cardiology; emergency medicine; myocardial infarction.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Twelve-lead ECG demonstrating ST depression in V2-V4 and RBBB with rSR’ in V1.
RBBB - Right bundle branch block
Figure 2
Figure 2. Fifteen-lead ECG demonstrating potential ST elevation but definite convex morphology in V8-V9.
Figure 3
Figure 3. Left circumflex culprit lesion identified through coronary catheterization.
See this image and copyright information in PMC

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