EKG of the Week 2017 11-5

This EKG comes courtesy of Dr. Eric Golike.

A 47 year old male with a history of HTN and high cholesterol was awoken from sleep with chest pressure through his mid chest. The pain is non-radiating. It began two hours prior to arrival in the ED and has been constant.

The EKG is below.

2017 11-5.jpg

1.       What does the EKG demonstrate?

2.       How should this patient be managed?



The EKG shows ST elevations in leads V2-V5, I and aVL with reciprocal depressions in leads II, III and aVF. There is an underlying right bundle branch block.

This EKG meets STEMI criteria. The patient should go to the cath lab for emergent PCI.


The EKG shows an underlying right bundle branch block (RBBB). The criteria for a RBBB are:

1.       Widened QRS complex

2.       RSR’ pattern in leads V1-V3

3.       Deep terminal S waves in leads V5, V6, I and aVL

4.       Secondary ST/T changes in leads V1-V3

In addition, there are ST elevations in leads V2, V3, V4, V5, I and aVL with reciprocal depressions in leads II, III and aVF. This represents an anterolateral acute MI.

A left bundle branch block can mimic ST elevations and can mask the presence of an MI. So, ST elevations in a left bundle branch block may not signify an acute MI. Sgarbossa’s criteria are needed to determine if the ST elevations represent an acute MI. However, a right bundle branch block does NOT mask ST elevations. So, if you see ST elevations in the presence of a right bundle branch block, it is indicative of an MI.

This patient was seen at a community hospital which does not have PCI capabilities. He was transferred to the University Hospital and went straight to the cath lab where he was found to have a 100% proximal LAD occlusion.

2017 11-5 cath pre PCI.jpg

Two stents were placed and flow was restored:

2017 11-5 cath post PCI.jpg