LBBB with RAD: Acute Inferior Infarction
Report:
Sinus rhythm 96-100/min
Third degree AV block
Junctional escape rhythm 45/min
Left bundle branch block
Right axis deviation +95o
Acute inferior infarction
Comment:
Three contributors to heart failure are present in this trace: Acute infarction, complete AV block and broad LBBB QRS complex.
LBBB does not always mask the primary ST/T changes of acute infarction: they would probably look very much the same if the conduction were normal. An unusual feature here is the RAD: it is a marker of congestive cardiomyopathy. This patient had severe heart failure, but not, exactly, a COCM. Some of the RAD might be due to the reciprocal ST depression in lead 1 “pulling” the terminal QRS down.
He went on to have CABGs but only incomplete revascularisation was possible. Over the next two years the frontal plane axis fluctuated between +70o and +105o, with LBBB throughout. His cardiac status deteriorated into a true COCM indistinguishable clinically from the primary variety. The axis settled around +100o (Fig 5a).
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