Electrocardiographic ST-segment elevation with prominent R waves in precordial leads

• Published in: Netherlands heart journal 2022-10, Vol.30 (10), p.490-492
• Main Authors: Andreou, A. Y., Pérez-Riera, A. R.
• Format: Article
• Language: English
• Subjects: Angina pectoris; Cardiology; Coronary vessels; Electrocardiography; Ischemia; Medical Education; Medical imaging; Medicine; Medicine & Public Health; Rhythm Puzzle – Answer; Veins & arteries
• ISSN: 1568-5888; 1876-6250
• DOI: 10.1007/s12471-022-01696-6

See PDF.] Electrocardiogram (ECG) during angina. a Atrial fibrillation, heart rate 74 bpm, QRS duration ~ 120 ms (no discernible change in relation to admission ECG), normal frontal QRS axis (75°), right bundle branch block and left septal fascicular block resulting in late and relatively unopposed predominantly left-to-right and posterior-to-anterior septal activation, with resultant prominent and anteriorly shifted mid-to-late QRS forces and leftward directed initial QRS forces, crescendo and decrescendo of R wave voltage in V1–V3 and V5–V6, respectively, and lambda-like ST-segment elevation pattern. b (left panel) R wave amplitude in V2–V3 > 15 mm. c (left panel) Absent septal Q waves in V5–V6. b, c (right panels) Admission ECG leads displaying R waves with markedly lower amplitude and septal Q wave in V5, respectively Fig. 2 [Images not available. First septal perforator artery (SPA), which arises immediately proximal to the stenosis, is also shown ECG showed intermittent changes compatible with a conduction disturbance or block in the left septal fascicle (LSF), which is a third distinct division of the left bundle branch proceeding to the middle third of the left septal surface towards the apex [1]. In our patient, ischaemic ST-segment elevation and LSFB were probably due to vasospasm at the site of the LAD artery lesion compromising blood flow in the first septal branch found in the immediate vicinity.