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This young male patient had a very atypical presentation for STEMI (near syncope and abdominal pain after smoking an unknown drug), but we can pretend that it was not atypical and think about how we would interpret the ECG:
My Interpretation:
Normally, in RBBB, the transition from rSR' to RS or to qRS is between leads V3 and V4. On this ECG, the transition is between V1 and V2. There is no R' wave in V2 or V3, thus there is no discordant ST depression and discordant negative T-wave, as one would normally see in these leads in RBBB. Instead, there is a wide S-wave, which in RBBB is usually followed by an upright T-wave, but not by ST elevation (in uncomplicated RBBB).
But this case is probably an exception: in a young male, when the S-wave is in leads V2 and V3 (which is very uncommon in RBBB), it may be normal to have some ST elevation, as young males usually have ST elevation in V2 and V3 (early repolarization) and in this case of RBBB, that ST elevation would not be hidden by the repolarization abnormalities (ST depression and T-wave inversion) which normally come with RBBB.
My admittedly invented diagnosis: RBBB with early transition, and with ST elevation due to early repolarization that is not obscured by RBBB because of the early transition.
In any case, when I was showed this ECG by a worried resident, I was quite sure it was not STEMI even before hearing the clinical history, and much moreso after. And he ruled out for MI.
Normal RBBB:
RBBB with anterior STEMI (LAD occlusion):
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| There is right bundle branch block with an rSR' in V1 and wide S-wave in lateral leads. The ST segment is elevated in V2-V4. Usually, in RBBB, the only secondary repolarization abnormalities are some minimal ST depression in V2 and V3 and there should not be ST elevation (see image of normal RBBB at bottom, and image of RBBB with anterior STEMI still further down). In the right context, might this be STEMI? Interpretation below. |
My Interpretation:
Normally, in RBBB, the transition from rSR' to RS or to qRS is between leads V3 and V4. On this ECG, the transition is between V1 and V2. There is no R' wave in V2 or V3, thus there is no discordant ST depression and discordant negative T-wave, as one would normally see in these leads in RBBB. Instead, there is a wide S-wave, which in RBBB is usually followed by an upright T-wave, but not by ST elevation (in uncomplicated RBBB).
But this case is probably an exception: in a young male, when the S-wave is in leads V2 and V3 (which is very uncommon in RBBB), it may be normal to have some ST elevation, as young males usually have ST elevation in V2 and V3 (early repolarization) and in this case of RBBB, that ST elevation would not be hidden by the repolarization abnormalities (ST depression and T-wave inversion) which normally come with RBBB.
My admittedly invented diagnosis: RBBB with early transition, and with ST elevation due to early repolarization that is not obscured by RBBB because of the early transition.
In any case, when I was showed this ECG by a worried resident, I was quite sure it was not STEMI even before hearing the clinical history, and much moreso after. And he ruled out for MI.
Normal RBBB:
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| There are secondary repolarization abnormalities: ST depression and T-wave inversion in leads with an R' (V1-V3) |
RBBB with anterior STEMI (LAD occlusion):
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| There is STE in V2 and V3 concordant with the R' wave. This was an acute LAD occlusion. |
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