Case 3

Sinusrhythm with left bundle branch block, comparison with an old ECG is mandatory to evaluate whether the LBBB is new (a sign of myocardial infarction) or old.

The ECG

• Following the 7+2 steps:
  • Rhythm
    • The ECG shows a regular rhythm with normal P waves (positive in I, III and AVF, negative in AVR), followed by QRS complexes. Sinusrhythm
  • Heart rate
    • 78 bpm
  • Conduction (PQ,QRS,QT)
    • PQ: 180ms QRS: 160ms QT: 370ms QTc: 420ms
  • Heartaxis
    • Negative in III, AVF and AVR, positive QRS complexes in I, II and AVL: horizontal heart axis
  • P wave morphology
    • The P waves have normal morphology.
  • QRS morphology
    • Wide QRS complexes with [[[LBBB|left bundle branch block]]] pattern.
  • ST morphology
    • ST elevation in V1-V3, AVR. ST depression in I, II, III, AVF, V4-6. The Sgarbossa criteria for ischemia in LBBB are not met (nog concordant ST deviation, no ST depression V1-V3, nog discordant ST elevation > 5 mm).
  • Compare with the old ECG (not available, so skip this step)
  • Conclusion?