The patient is an 84-year-old male who presents with chest discomfort on exertion of a more frequent occurrence and increasing shortness of breath. He has had an aortic outflow murmur and a history of "aortic stenosis." A few months ago, he had cardiac catherization with a stent performed at an outside hospital. He is seen in the emergency department and the following ECG was recorded:
The ECG shows which of the following?
The correct answer is: C. Right bundle branch block and posterolateral infarction of undetermined age.
The patient is in sinus rhythm with a rate of 62 beats per minute. The frontal plane axis is approximately -30° and the PR interval is normal. The QRS is wide (duration of 136 ms) with a typical right bundle branch block (RBBB) morphology. A prominence of the initial R wave size and duration is present in lead V1 and V2. The T wave is also upright; the T wave should be oriented away from the R wave in typical RBBB. The T wave would be inverted in V1, V2 and possibly V3 if right ventricular enlargement was present.
This upright T wave in V1 and V2 is indicative of posterolateral infarction of undetermined age. The patient had a large postero-lateral defect as well as significant aortic stenosis.
Madias JE, Bravidis D and Attari M. Posterior myocardial infarction and complete right bundle branch block. Chest. 2002 Nov;122(5):1860-4. doi: 10.1378/chest.122.5.1860.