Acute Dyspnea and Right Bundle Branch Block

I was texted this ECG just as I was getting into bed.It is of an elderly woman who complained of shortness of breath and had a recent stent placed.I was told that the Queen of Hearts had called it OMI with high confidence.What do you think? Ken (below) is appropriately worried about pulmonary embolism from the ECG. What I had not told him before he made that judgement is that the patient also had ultrasound B-lines of pulmonary edema.Here is my interpretation:There is sinus rhythm with RBBB.  If you jump to looking at ST segments, you see " coved " ST in V3, V4, V5, with subtle ST Elevation.  This is HIGHLY suspicious for OMI.  But you must look at the entire QRST:there are QR-waves in V1 and V2. LV aneurysm has QS-waves, so this couldn ' t be LV aneurysm, right?  WRONG!  RBBB makes it mandatory that there are R ' -waves even in the presence of LV aneurysm.  A patient with normal conduction and QS-waves who then develops RBBB will have QR-waves!!  See this post: Dyspnea, Right Bundle Branch block, and ST elevationMoreover, the T-waves are not upright, so if this is OMI it is likely a reperfused OMI.  (IMPORTANT: in version 1, the Queen does not differentiate between active and reperfused OMI, so if this is a subacute OMI, she will still call it " OMI " ).Additionally, it is very difficult to differentiate subacute reperfused OMI from LV aneurysm: both have Q-waves and inverted T-waves.  If it is subacute, t...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs