ECG Review: RBBB with Acute STEMI?

By Ken Grauer, MD, Professor Emeritus in Family Medicine, College of Medicine, University of Florida. Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book.


Figure — ECG obtained from a 62-year-old man with a history of presyncopal episodes.

Scenario: The ECG shown above was obtained from a 62-year-old man who presented to the emergency department with a history of several presyncopal episodes in recent months. His ECG was diagnosed as showing acute anterior ST elevation myocardial infarction (STEMI). Do you agree? What treatment is indicated?

Interpretation: The ECG shows sinus bradycardia at a rate just under 60/minute. All intervals and the axis are normal. There is no chamber enlargement. There may be slight J-point ST elevation in lead I, and some nonspecific ST depression in inferior and lateral precordial leads. That said, the area of most concern clearly relates to findings in leads V1 and V2.

• There appears to be an rSr’ complex in V1, V2.

• There is an elevated J-point in each of these leads with an unusual type of downsloping ST segment that is especially marked in lead V2. The ST segment terminates in shallow T wave inversion.

The ECG findings in the figure are highly suggestive of Brugada syndrome. First described in 1992, the Brugada syndrome is important to recognize because of an associated very high risk of sudden death. The prevalence of this disorder is approximately 1/2000 in the general population. Brugada syndrome is a leading cause of sudden death in adults under the age of 40.

Bottom Line: Although serial tracings and troponins are advised, the ECG in the figure is not suggestive of acute STEMI. It is also not representative of right bundle branch block. Instead, the tracing shows characteristic findings of Brugada syndrome. Cardiology consultation should be obtained — and implantable cardioverter defibrillator placement is advised.

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