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Tell me about these ECG

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"electrocardiography"[MeSH Terms] AND "right bundle branch block"

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2025 guideline ECG right bundle branch block ST T wave abnormality ischemia

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ACC chest pain guideline ECG new T wave inversions emergency evaluation symptoms

This ECG is abnormal, but it does not show clear ST-elevation myocardial infarction (STEMI) criteria on this photo.

What it appears to show

  • Sinus rhythm, about 87 beats/minute. Each beat seems to be preceded by a P wave.
  • PR interval 152 ms, within the usual range.
  • Wide QRS: 156 ms, consistent with a complete right bundle branch block (RBBB). This is also the machine interpretation. In RBBB, electrical activation of the right ventricle is delayed, producing a widened QRS and characteristic terminal changes in V1 and V6. This tracing's QRS duration is well above the 120 ms threshold for complete rather than incomplete block.
  • Machine-reported QTc about 471 ms, which is borderline prolonged for a male. QTc interpretation depends on the correction formula, medications, potassium/magnesium/calcium levels, and repeat ECGs.
  • ST-T / T-wave changes in the inferior leads (II, III, aVF), reported by the machine as possibly ischemic. I can see repolarization abnormalities there, but an image alone cannot determine whether these reflect acute ischemia, an older baseline finding, RBBB-related secondary changes, lead placement, or another cause.
  • The printout also flags possible left atrial abnormality, which requires confirmation and often an echocardiogram only if clinically indicated.

How concerning is it?

An RBBB may be an incidental longstanding finding, especially if isolated, but it can also occur with structural heart disease, pulmonary disease or pulmonary embolism, ischemia, or other conditions. The inferior ST-T abnormalities should not be dismissed, particularly if they are new or there are symptoms.
T-wave inversion is not specific for a heart attack, but new, deep, or dynamic ST-T changes with ischemic symptoms require urgent assessment. The ACC chest-pain pathway recommends comparison with prior ECGs, serial ECGs, and appropriate cardiac testing when ECG changes may be ischemic. ST-segment and T-wave changes can occur during myocardial ischemia, as described in Medical Physiology, p. 884-887. RBBB typically has a terminal rightward/anterior QRS vector, often an rSR' pattern in V1 and qRS in V6, as described in Harrison’s Principles of Internal Medicine 22E, p. 1373.

What to do

Go to an emergency department now or call emergency services if this ECG belongs to someone with any current or recent:
  • chest pressure, tightness, heaviness, or pain
  • shortness of breath
  • sweating, nausea/vomiting
  • fainting, marked dizziness, palpitations
  • pain in the jaw, arm, shoulder, back, or upper abdomen
If there are no symptoms, arrange prompt clinician or cardiology review, ideally with:
  1. Comparison with any older ECG
  2. Repeat 12-lead ECG
  3. Blood tests if clinically appropriate, including high-sensitivity troponin and electrolytes
  4. Consideration of echocardiography based on history/examination
The automated ECG statement is explicitly “unconfirmed,” and a photo cannot replace a clinician reading the original tracing in context.
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