Atypical LBBB: Anterolateral Q Waves

Report:

Sinus rhythm

SVEBs, runs of SVT

Left axis deviation –50o

Intraventricular conduction delay, probably atypical left bundle branch block

Probable old anterior infarction

ST/T changes suggest infarction/ischæmia.

Comment:

Post-arrest ECGs (and enzymes) are often difficult to interpret; fortunately it does not really matter that much whether the patient had actual infarction or only ischaemia. His future depends on his coronary anatomy.

The following day the ST segments resumed their usual position (below, Fig 48a), similar to that of pre-admission traces (not shown).

The QRS delay is all in the left ventricular territory, but the Q waves make the diagnosis of LBBB difficult. They indicate anteroseptal infarction in LBBB, although many patients with LBBB and anteroseptal infarct do not have them. IVCD is a safe diagnosis. John Morgan, Director of Cardiology at St. Vincent’s Hospital in Sydney, gave me this excellent advice when I asked him how to report ECGs: “Under-report them!”.