Nonspecific symptoms with RBBB and New ST Elevation. Anterior STEMI, right? What does the echo show?

A 50-something male with a history of COPD and substance use disorder who presented with generalized weakness and exacerbation of chronic back pain that is now radiating to his neck, and headache. He also developed nausea, alternating " hot and cold flashes " , and generalized weakness the previous evening. He became anxious about his symptoms and then used crack cocaine as well as drank alcohol last night. His symptoms have persisted since then. He states he has felt short of breath since last night. He denies any chest pain, though notes he has a " odd " sensation in his chest. Vital signs were normal and physical exam was unremarkableHe had an ECG recorded:This is RBBB, which normally does not have ST Elevation anywhere.  In fact, it normally has ST depression in V1-V3 that is discordant to the previous R ' -wave.  In this case, there is no R ' -wave in V1, which is unusual in RBBB.  V2 and V3 do have rSR ' , and both of those also have ST elevation that is concordant to the R ' -wave.  This usually is an indicator of LAD occlusion.There was a previous ECG from 3 months priorThis ECG does have an R ' -wave in V1, and (appropriately) without STE.  V2 and V3 are lacking an R ' -wave; in fact, they have a wide S wave which is usually only seen in lateral leads of RBBB.  There is STE which is discordant to that wide S-wave; usually the ST segment in RBBB is isoelectric even AFTER the wide S-wave.So this is an abn...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs