Monday, April 6, 2009

Right BBB and Bigeminy, with Anterior STEMI

This is from a 53 year old male smoker with chest pain.
Here is the initial EKG:
There is grouped beating, in couplets. Both complexes in each couplet are wide. the first complex in each couplet is preceded by a p-wave. If you look at the first of each couplet in V1 and V6, they have RBBB morphology. So this is bigeminy with RBBB. Obviously, the ST and T wave are very abnormal, with huge ST elevation due to LAD occlusion.

In the inferior leads, there appears to be ST elevation in both complexes, but this is not so: what appears to be STE is really just a prolonged QRS.

Thanks to Dave for this case:


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  3. sinus bradycardia with bigeminy PVC, retrograde atrial capture, RBBB, anteroseptal and inferolateral myocardial injury. definitely LAD occlusion

  4. There is indeed LAD occlusion, and lateral injury, but NO inferior injury. What appears to be ST elevation in inferior leads is only a prolonged QRS. There is indeed minimal STE in II and aVF, but there is, in fact, reciprocal ST depression in lead III.

  5. But there is still RBBB with concordant T waves in the inferior leads, doesn't that speak for ischemia, too?

    1. The limb lead ischemia is in I and aVL, with some subtle ST elevation. (anterolateral STEMI from proximal LAD occlusion). In RBBB, T-waves are often concordant with the upright R-wave. They are, however, usually discordant with the wide S-wave (or R' wave in V1-V3).