What is the Diagnosis?

A 60 yo woman presented with CP and troponin I of 0.85 ng/ml.

There is RBBB, but without the usual rSR' in right precordial leads.  [There is some left axis deviation as well, probably a left anterior fascicular (hemi-) block.]  The initial r-wave is gone, so that there are QR-waves (diagnostic of myocardial infarction, whether old or acute).  There is ST elevation (which is never normal in RBBB).  The negative T-wave makes it very unlikely that this acute MI, but it could be either subacute or old. 






My interpretation was RBBB with old anterior MI and LV aneurysm.  We admitted her treated her for NonSTEMI.

Subsequent course:

There was no ECG evolution.  Echo showed decreased left ventricular systolic performance, at least moderate, with an estimated EF = 35 - 40%.  There was a regional wall motion abnormality in the LAD distribution: distal septum, anterior and apex, large and the wall was "akinetic or possibly dyskinetic," confirming LV aneurysm.  There was also a left ventricular apical thrombus, which is a frequent complication of aneurysms. 

She was treated medically for her NonSTEMI and LV thrombus.

Here is a very detailed discussion of RBBB with LV aneurysm, with several ECGs.