ECG Strip 31


ECG Strip 31 - RBBB ischemia

A patient comes into the outpatient because of recurring chest pain, at the time of examination is without any acute problems. The initial ECG is above. We can see RBBB (already described in patient’s medical history two years ago), ST segment depressions in chest leads, deep Q and negative T in III, deep S in lead I and isolated ST elevation in III. S1Q3T3 and RBBB could be related to pulmonary embolism. The isolated ST elevation in III is unclear but together with ST depressions in chest leads it can be related to a cardiac ischemia.


During the conversation, the patient begins to complain about a sudden chest pain and dizziness and right in front of my eyes falls unconscious to the ground. There is no palpable pulse, we start cardiopulmonary resuscitation and call for help of the intensive care emergency unit. During the resuscitation we are able to restore cardiovascular functions and record another ECG with a completely different finding:

ECG Strip 31 - third-degree AV block LBBB


In this ECG we see a total atrioventricular dissociation typical for third-degree AV block (I have marked visible P waves by red color in lead II) and RBBB changed into a full LBBB. There are probably ST segment elevations in V1-V4, which would correspond with a STEMI infarction of the anterior heart wall. According to the clinical state and ECG finding, the most probable diagnosis is an acute coronary syndrome. The patient is quickly transported to the intensive care unit for further treatment. Unfortunately, a cardiac shock quickly develops causing death of this patient no matter further resuscitation attempts. The autopsy confirms an ulcerated atherosclerotic plate that obstructed the right coronary artery.


Jiri Stefanek, MD  Author of texts: Jiri Stefanek, MD
 Sources: basic text sources