ECG ASSIGNMENT

Sujan Rachel
(CVT II YEAR- 2411BS040063)
 BBB- Bundle Branch Block

SYMPTOMS
• Chest pain
• Extreme fatigue
• Shortness of breath
• Dizziness
• Fainting
RBBB- Right Bundle Branch Block
Examples - 1
Complete Right Bundle Branch Block (RBBB)

ECG Findings:

1. QRS duration ≥ 120 ms (wide QRS).

2. RSR' pattern in V1-V2 ("rabbit ears" /M-shaped QRS).

3. Wide, slurred S wave in leads I and V6.

4. Secondary ST-T changes:

ST depression and T wave inversion in right precordial leads (V1-V3).

5. Normal or right axis aviation may be seen.

RBBB- Right Bundle Branch Block
Examples - 2
Incomplete RBBB (iRBBB)

ECG Criteria / Findings

1. QRS duration < 120 ms (narrower than complete RBBB).

2. RSR' pattern in V1-V2 (M-shaped / "rabbit ears").

3. Terminal S wave in leads I and V6 (but less wide than in complete RBBB).

4. Normal ST-T segments (usually no secondary repolarization abnormalities, unlike

complete RBBB).

5. Often considered a normal variant (especially in young, healthy individuals).

RBBB- Right Bundle Branch Block
Examples – 3
Findings of Myocardial Infarction in the presence of RBBB:

ST-segment elevation (or depression) not explained by RBBB.

Pathological Q waves in infarcted leads (may still be seen even with RBBB).

Loss of R wave progression in anterior leads if anterior MI.

Concordant ST elevation or depression (in the same direction as QRS) → highly

suggestive of MI.

New RBBB with chest pain → often indicates proximal LAD occlusion (acute anterior MI,
high risk).
 RBBB- Right Bundle Branch Block
Examples – 4
ECG Changes Suggestive of Pulmonary Embolism/Cor Pulmonale:

1. Acute Right Heart Strain: 2. Right Ventricular Strai Pattern:

S1Q3T3 pattern: T wave inversion in V1-V4 (sometimes extending

to inferior leads II, III, aVF).
Prominent S wave in lead I,
Right axis deviation (QRS axis > +90°).
Q wave in lead III,

Inverted T wave in lead III.

Seen in ~10-20% of PE patients, but

very suggestive when present.
LBBB- Left Bundle Branch Block
Examples - 1
ECG findings of Complete LBBB

1. QRS duration > 120 ms (broad complex).

2. Absent Q waves in leads I, V5, V6 (except aVR).

3. Wide, notched or slurred R waves in leads I, V5, V6 ("M-shaped").

4. Deep, broad S waves in right precordial leads (V1-V3).

5. ST-T changes (discordant to QRS):

ST depression and T wave inversion in left-sided leads (I, V5, V6).

ST elevation in right precordial leads (V1-V3).

LBBB- Left Bundle Branch Block
Examples - 2
ECG findings of Incomplete LBBB

1. QRS duration < 120 ms (narrower than complete LBBB).

2. LBBB pattern preserved:

Absent Q waves in leads I, V5, V6.

Wide / slurred / notched R waves in leads I, V5, V6.

Deep and broad S waves in leads V1-V3.

3. ST-T abnormalities (discordant to QRS):

ST depression and T inversion in left-sided leads (I, aVL, V5, V6).

ST elevation in right precordial leads (V1-V3).

LBBB- Left Bundle Branch Block
Examples - 3
LBBB with Myocardial infraction

MI Findings in Presence of LBBB

LBBB makes infarction hard to diagnose, but some key criteria help:

Sgarbossa Criteria (for MI in LBBB):

1. Concordant ST elevation ≥ 1 mm in leads with positive QRS → highly specific for MI.

2. Concordant ST depression ≥ 1 mm in V1-V3 suggestive of posterior MI.

3. Excessively discor

ST elevation ≥ 5 mm in leads with negative QRS

LBBB- Left Bundle Branch Block
Examples - 4
LBBB in dialated Cardiomyopathy

1. QRS duration ≥ 120 ms (broad).

2. Absent Q waves in leads I, V5, V6 (except aVR).

3. Wide, notched or slurred R waves in leads I, aVL, V5, V6.

4. Deep, broad S waves in V1-V3.

5. ST-T changes discordant to QRS:

ST depression and T inversion in leads with tall R waves (I, aVL, V5-V6).

ST elevation in leads with deep S waves (V1-V3).

STEMI –
ST Elevated Myocardial Infraction
AWMI – Example 1
Extensive Anterior STEMI
1. ST-segment elevation in:

V1 to V6 → indicating septal and anterior wall involvement

Lead I and aVL indicating high lateral wall involvement

2. Reciprocal ST-segment depression:

Often seen in inferior leads (II, III, aVF)

3. Q waves:

May develop later in V1-V4, indicating myocardial necrosis

4. Loss of R wave progression in precordial leads

5. T wave inversion may follow ST elevation as the ct evolves

STEMI –
ST Elevated Myocardial Infraction
AWMI – Example 2
Isolated Anterior STEMI

ST-segment elevation in precordial leads V2 through V5,

often without involvement of lateral (I, aVL, V6) or
inferior leads. NOBI

Absence of reciprocal ST depression in inferior leads (II,

III, aVF) distinguishing it from more extensive or
anterolateral MIs. NCBI

This pattern suggests an occlusion of the distal LAD,

sparing septal and lateral branches. NCBI
STEMI –
ST Elevated Myocardial Infraction
AS wall MI – Example 1
Classic STEMI

Pronounced ST-segment elevations across the

precordial leads V1 through V6 (reflecting septal and
anterior wall involvement)

Elevation also noted in the high lateral leads (I and aVL)

Reciprocal ST depressions in the inferior leads (e.g III

and aVF)
STEMI –
ST Elevated Myocardial Infraction
AS wall MI – Example 2
Atypical AS wall MI in a Diabetic patient
Interpreting This ECG (Atypical AS Wall MI in a Diabetic Patient)

In the context of your scenario-an atypical anteroseptal MI in a diabetic patient-here's what we'd
expect to observe:

ST-segment elevation in precordial leads V1-V4, indicating ischemia of the septum and adjacent
anterior wall-typically supplied by the left anterior descending (LAD) artery NCBI [Link]

[Link]

Q waves may begin to develop in V1-V3, particularly if the infarct is evolving or

older Clinical Gate ResearchGate

Hyperacute (peaked) T waves may precede ST elevation, especially in early

phases
STEMI –
ST Elevated Myocardial Infraction
AL wall MI – Example 1
Classic Anterolateral STEMI ECG Findings:

ST elevation in leads I, aVL, V4, V5, V6

May have some ST elevation in V3 as extension into the anterior wall

Reciprocal ST depression in inferior leads (II, III, aVF)

STEMI –
ST Elevated Myocardial Infraction
AL wall MI – Example 2
Isolated Lateral STEMI

ST Elevation: Noted prominently in the lateral leads (I, aVL, V5-V6) indicating
localized injury to the lateral wall of the left ventricle.

Reciprocal ST Depression: Present in the inferior leads (III, aVF)-a mirror image
change that often accompanies STEMI patterns.

No Involvement of Other Territories: There is an absence of ST changes in

anterior or inferior leads, supporting that the infarction is confined to the lateral
wall.
IWMI –
Inferior wall Myocardial Infraction
AWMI – Example 1
Classic IWMI
• ST-Segment Elevation in II, III, and aVF, indicating an infarct in the inferior wall of
the left ventricle, typically supplied by the right coronary artery (RCA).

• Reciprocal ST-Segment Depression in the high lateral leads I and aVL, which
further supports the inferior location of the infarction.

• Pathologic Q waves may develop in inferior leads during the subacute phase,
reflecting necrosis.

• Often associated with RCA occlusion-especially when ST elevation in lead III

exceeds that in lead II, suggesting a right-sided vector.
IWMI –
Inferior wall Myocardial Infraction
IWMI – Example 2
IWMI with right ventricular Myocardial Infraction

•Inferior Wall STEMI Indicators:

•ST elevation in leads II, III, and aVF, signaling an inferior wall infarction, most
often due to right coronary artery (RCA) occlusion.

•Reciprocal ST depression in leads I and aVL, adding diagnostic confidence.

•ECG Guru Instructor Resources

•ECG Book

•Right Ventricular Infarction Indicators: A

IWMI –
Inferior wall Myocardial Infraction
IWMI – Example 3
IWMI from left circulmflex occulsion

• ST elevation in inferior leads (II, III, aVF) is present.

• Unique to LCx occlusion (especially if LCx is dominant):

• ST elevation in lead II ≥ III, signaling a leftward-directed injury vector.

• Absence of reciprocal ST depression in lead I, helping differentiate from RCA

infarction.

• Additional evidence may include:

• ST elevation in lateral leads (I, aVL, V5-V6) if there's lateral wall involvement.

• Reciprocal ST depression in leads aVR, further supporting an LCX pattern.

 IP wall MI

Example 1
Infero posterior MI due to RCA occulsion

ST Elevation in Inferior Leads (II, III, aVF): Clearly indicates an inferior

wall myocardial inforation involvement.

Reciprocal ST Depression in V1-V2: Reflective of posterior wall infarction-

a mirror change, as these leads face the area from the front. The tall R waves
in V1-V2 further represent a posterior "mirror" of Q waves.

ST Elevation in Lead III > Lead II: Strongly suggests that the occlusion is in
the RCA, as opposed to the LCx.

Reciprocal ST Depression in aVL (and Possible in Lead 1): Supports the

localization of the infarct to the inferior wall, again pointing toward RCA
occlusion.
 IP wall MI
Example 2
Inferio Posterior MI due to LCx occulsion

ST elevation in inferior leads (II, III, aVF): Signifies infarction of the

inferior wall-common in both RCA and LCX occlusions.

ST elevation in lead II equal to or greater than lead III, without

reciprocal ST depression in lead I: A key hint toward LCx involvement
rather than RCA, where ST elevation typically is greater in lead III and often
shows reciprocal
changes in lead I.

Potential ST elevation in lateral leads (1, aVL, V5-V6): This suggests

lateral or posterolateral wall involvement-territory supplied by the LCx
artery.

ST depression in anterior leads (V1-V3): Represents reciprocal (mirror-

image) changes from posterior wall ischemia, a typical sign of posterolateral
in ment-often seen with LCx occlusion.
 IL wall MI
Example 1
Infero lateral MI LCx occulsion
ST Elevation in:

• Inferior leads: II, III, AVF

• Lateral leads: I, aVL, V5, V6

This wide territory involvement suggests a large infarction including the
inferior and lateral walls.

ST Depression in V1-V3:

• Represents reciprocal (mirror-image) changes indicating posterior wall

involvement, a hallmark of infarct extension in LCx occlusions.

II ≥ III (more elevation in lead II than III):

• A leftward-inferior injury vector suggestive of LCx, rather than RCA,

especially in left-dominant anatomy.
 IL wall MI
Example 2
Infero Lateral MI due to wraparound LAD occulsion

ST Elevation in Inferior Leads (II, III, aVF): Indicatos involvement of

LITE inferior wall.

ST Elevation in Lateral Leads (I, aVL, V5-V6): Suggests lateral wall

involvement.

ST Depression in aVR and V1-V3: Reflects reciprocal changes from

posterior wall involvement.
 PWMI
Example 1
Isolated posterio MI

This ECG displays hallmark signs of a true posterior MI:

• Horizontal ST-segment depression in leads V1-V3, which are actually

reciprocal changes reflecting posterior ST elevation.

• Tall, broad R-waves in V2-V3-these represent "mirror" Q-waves from

the posterior wall infarction.

• Upright T-waves in these leads, further supporting the posterior

injury pattern.

• When a posterior ECG is recorded (in leads V7-V9), modest ST

elevation (≥ 0.5 mm) is typically visible, confirming the diagnosis
 PWMI
Example 2
Inferio posterio MI

ST elevation in the inferior leads (II, III, aVF): Reflects acute

injury to the inferior wall.

Deep, horizontal ST depression in anterior leads (V1-V3):

These are the reciprocal, mirror-image changes of posterior wall
ST elevation.

Tall R waves in V1-V3: These represent the "mirror" of posterior

Q waves, pointing toward posterior wall involvement.

Prominent upright T waves in the same leads: Further support

the mirror-image phenomenon typica' of posterior infraction.
 PWMI
Example 3
Inferio lateral MI

What to Look for in a Posterolateral MI ECG

Reciprocal ST-segment depression in anterior leads (V1-V3),

which mirror actual ST elevation in posterior wall territories-often
not visible on the standard 12-lead ECG.

Tall, broad R waves and upright T waves in V1-V3-representing

mirror-image Q waves and T-wave inversions from the posterior
wall.

The posterolateral region is best visualized using posterior leads

(V7-V9). ST elevation in these leads (≥ 0.5 mm) confirms the
infarct.
 RVMI
Example 1
RVMI with Inferior MI

ST Elevation in Inferior Leads (II, III, aVF): These findings confirm the
presence of an inferior wall MI, typically due to proximal right coronary
artery (RCA) occlusion, Life in the feat Lane TEL

ST Elevation in V1 (or Isoelectric with ST depression in V2): On a standard

ECG, elevation in V1-or an isoelectric V1 with marked ST depression in V2-
strongly suggests right ventricular involvement. Life in the Fast Lane-LITFL

ST Elevation in Right-Sided Lead V4R (if recorded): A V4R ST elevation ≥1

mm is highly sensitive and specific (up to 92% accuracy) for confirming
RVMI.

Greater ST Elevation in Lead III than Lead II: This pattern reflects a
rightward and inferior injury vector often associated with R occlusion
impacting the RVMI
 RVMI
Example 2
Isolated RVMI

ST-segment elevation in lead V1, which is the only standard

12-lead ECG lead directly viewing the right ventricle.

ST elevation in V1 paired with ST depression in V2 is highly

specific for RV infarction and is a red flag when

ST elevation in lead III greater than lead II supports RCA

occlusion with potential right ventricular involvement.
 RVMI
Example 3
RVMI with posterior MI

1. Inferior Wall Involvement

ST elevation in leads II, III, and aVF, confirming an inferior myocardial

intarction.

A typical right coronary artery (RCA) territory infarct.

2. Right Ventricular Infarction (RVMI) Clues

ST elevation in V1 or isoelectric V1 with pronounced ST depression in V2 is

highly suggestive. A

ST elevation in lead III > II also supports RV involvement due to a rightward-

injury vector.

ST elevation in right-sided lead V4R (if recorded) is diagnostic.

 NSTEMI
Example 1
NSTEMI with diffuse sub endocardial Ischemia

Diffuse ST-segment depression across multiple leads,

especially in the inferior and anterolateral territory-such as
V4-V6 and lead II. These depressions are typically horizontal
or downsloping, indicating ischemia rather than benign
changes.

ST-segment elevation in lead aVR, often accompanied by a

reciprocal rise in V1, reflecting a global subendocardial
Ischemic vector directed toward the right shoulder.
 NSTEMI
Example 2
Posterior NSTEMI

The top panel shows a standard 12-lead ECG with:

• Horizontal ST depression in anterior leads V1-V3

• Tall, broad R waves and upright T waves in the same leads

These patterns are highly suggestive of posterior ischemia and

may easily be misinterpreted as mere subendocardial changes.

The bottom panel-recorded with posterior leads V7-V9-reveals:

• ST-segment elevation in these posterior leads (even as little as

≥0.5 mm is diagnostic)
 NSTEMI
Example 3
NSTEMI in a high risk Elderly patient

T-Wave Inversion in Leads II, III, and aVF, V4-V6: These

changes-especially when new-suggest myocardial ischemia in
the inferolateral region, consistent with NSTEMI.

No ST-Segment Elevation: This underscores the "non-ST-

elevation" nature of the infarction.

Elevated Troponin Levels with Clinical Symptoms: Such

findings confirm myocardial injury and classify the event as
NSTEMI rather than unstable angina. ([turn0search2]
Thank You