Leads II, III and aVF show inferior wall.

  Recent development of ST segment elevation in these leads suggest

      acute inferior wall myocardial infarction.



RBBB and acute myocardial infarction

  RBBB does not interfere with the diagnosis of acute myocardial infarction.

  Presence of RBBB shows poor prognosis in patients with coronary artery disease.

  New-onset RBBB during acute myocardial infarction has a worse prognosis than old RBBB.

      (On the contrary, in acute anterior wall myocardial infarction and left bundle branch block (LBBB),

      the mortality rate with old LBBB is higher than new-onset LBBB.)




ECG 1a. This ECG is from a patient who applied to the Emergency Room with the complaint of retrosternal chest pain. There is
ST segment elevation in leads II, III and aVF, while reciprocal ST segment depression is observed in leads I and aVL.
Nonconducted P waves and bradycardia is seen due to complete atrioventricular (AV) block (heart rate is 36/min.).
Complete AV block occurs more frequently in inferior wall myocardial infarctions.

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ECG 1b. This is the right-sided ECG from the same patient. ST segment elevation in leads C4R, C5R and C6R show that acute
right ventricular myocardial infarction also exists.

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ECG 2a. The ECG above belongs to a 58 years-old man with chest pain and shows acute inferior myocardial infarction.
There is also nodal rhythm. No P waves preceed QRS complexes. The ST elevation and tall T waves in inferior leads show
acute inferior myocardial infarction. The ST segment depression in I, aVL and anterior leads are reciprocal changes.
After this ECG was recorded, the patient underwent immediate coronary angiography and the right coronary artery was
stented successfully.

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ECG 2b. The next day, nodal rhythm disappeared and sinus rhythm was restored. Second beat from the left is atrial premature
contraction. There are only small q waves to suggest old inferior myocardial infarction.

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ECG 3a. The ECG above belongs to a 59 years-old man. It was recorded in the Emergency Room. He had undergone
coronary artery bypass graft surgery 2 years ago. The ECG shows right bundle branch block (RBBB) , ST segment elevation
and tall T waves in inferior leads. Thrombolytic therapy with Tenecteplase was administered immediately after recording of
the above ECG. The time of onset of the RBBB in relation to infarction was uncertain in this patient.

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ECG 3b. One hour after tenecteplase, the ST segment elevation and tall T waves in inferior leads have disappeared. He does
not have chest pain now. Disappearance of chest pain with the regression of ECG signs suggest successful recanalization of
the infarct-related artery.

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ECG 4a. A 60 years-old man was admitted to the emergency room with recent-onset chest pain.
The ECG showed only subtle ST segment elevation in the inferior leads.
Frequent Atrial Premature Contractions (APC) are also seen.
Ten minutes later after recording of the above ECG, he underwent coronary arteriography.

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ECG 4b. The ECG above belongs to the same man and was recorded 10 minutes after stenting of the Right Coronary Artery
(RCA).

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ECG 4c. The ECG above was recorded 8 hours after stenting of the RCA.

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Figure 4a. His left coronary angiogram showed a significant stenosis (but not infarct-related lesion)
at the distal Circumflex (Cx) coronary artery.



Figure 4b. The right coronary arteriogram showed that his infarct-related artery was
the dominant Right Coronary Artery (RCA).




ECG 5. Sinus bradycardia during acute inferior myocardial infarction. The heart rate is approximately 25/minute.
Inferior leads show ST segment elevation.
Due to low amplitude P waves, it may seem like nodal rhythm at first glance.
Immediately after recording of the above ECG, the patient underwent coronary angiography which revealed 99% stenosis of
the proximal Right Coronary Artery (RCA).

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ECG 6. The ECG above belongs to a 54 years-old man experiencing acute inferior wall myocardial infarction due to
occlusion of right coronary artery (RCA). This ECG was recorded before stenting of his RCA.
Leads related to the inferior wall (II, III and aVF) show ST segment elevation.

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ECG 7a. The ECG above belongs to a 56 years-old woman experiencing chest pain due to acute inferior wall
myocardial infarction. Inferior leads show ST segment elevation.
Immediately after recording of the above ECG, the patient received sublingual nitroglycerine and
the pain disappeared in a few minutes.
Still, the patient underwent coronary angiography and almost normal coronary arteries were observed.
The myocardial infarction was due to coronary spasm which was relieved by sublingual nitroglycerine.

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ECG 7b. The ECG above belongs to the same woman. It was recorded 14 hours after recording of the ECG 7a.
Now the ST segment elevation is not seen and the patient has no chest pain.

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ECG 8a. The ECG above belongs to an 80 years-old woman with acute inferior wall myocardial infarction.
Leads III and aVF show ST segment elevation while leads I, aVL and V1 show ST segment depression.
The rhythm is nodal rhythm with a heart rate of 44/minute. P waves are not visible.
This ECG was recorded immediately before stenting of her Right Coronary Artery (RCA).

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ECG 8b. The ECG above belongs to the same woman. It was recorded one day after the ECG 8a.
Now, the rhythm is low atrial rhythm with negative P waves in inferior leads
The heart rate is 61/minute and compatible with ectopic atrial rhythm. She is not under beta blocker therapy.

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