Right Bundle Branch Block with New Anterior ST elevation

An elderly female with no known history of CAD presented to the ED as a walk-in with vomiting and upper abdominal discomfort.  The following ECG was recorded at t = 0:There is sinus rhythm with Right Bundle Branch Block and ST elevation in leads V1 and V2, suspicious for STEMI. The computerized QRS duration is 138 ms.   A previous ECG was found:There is an RSR' with right ventricular conduction delay and downsloping ST depression in V1 that is reminiscent of Brugada pattern.  The computerized QRS duration is 84 ms.  The ST elevation is confirmed to be new.The cath lab was activated but the interventionalist was busy with another case.  In the interim, more data was found:  The first troponin returned elevated slightly.  A stat echo was ordered.  Heparin, Plavix and Nitroglycerine were ordered.  After ondansetron, the nausea subsided.  Further history revealed that the patient had undergone ablation for atrial fibrillation 7 days prior.  She had been on propafenone but was changed to flecainide following her ablation.  She was also on dabigatran (Pradaxa).  Her Na returned at 124 mEq/L.  Echo was completed and there was EF of 65% with no wall motion abnormality.  Repeat ECGs are below:2nd ECG, t = 50 minutes3rd ECG, t = 100 minutes There is little evolution of ST elevation.  The absence of a wall motion abnormality makes anterior STEMI very unlikely. It was decided that the changes were d...
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