History: This woman in her 20's (age) with history of repaired Tetralogy of Fallot presented with CP. Here is her presenting ECG:
I was very suspicious of anterior STEMI, and found a previous ECG from 4 months prior:
Very large RR’ in V1: RBBB and RVH, also LAFB |
Baseline ST depression in V1-V3, typical for RBBB. There is no ST elevation anywhere, also typical for RBBB.
An immediate echo confirmed new anterior-apical-septal wall motion abnormality, as well as RVH and LVH, and the patient was taken for angiography, which revealed fresh non-occlusive thrombus in the left main that extended down and occluded the LAD. The patient went for bypass surgery.
1. RBBB should not have ST elevation at baseline
2. In RBBB, there should be some ST depression in V2 and V3. An isoelectric ST segment may represent relative ST elevation.
3. A previous ECG can be very helpful
4. Echocardiography did confirm the findings, but delayed therapy. The ECG was diagnostic.
5. ST elevation can be found even when the QRS appears very distorted.