Lesson IX - Myocardial Infarction

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MI + Left Bundle Branch Block

Often a difficult ECG diagnosis because in LBBB the right ventricle is

activated first and left ventricular infarct Q waves may not appear at the
beginning of the QRS complex (unless the septum is involved).

Suggested ECG features, not all of which are specific for MI include:

Q waves of any size in two or more of leads I, aVL, V5, or V6

(See below: one of the most reliable signs and probably indicates
septal infarction, because the septum is activated early from the
right ventricular side in LBBB)

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Reversal of the usual R wave progression in precordial leads

(see above )

Notching of the downstroke of the S wave in precordial leads to

the right of the transition zone (i.e., before QRS changes from a
predominate S wave complex to a predominate R wave complex);
this may be a Q-wave equivalent.

Notching of the upstroke of the S wave in precordial leads to the

right of the transition zone (another Q-wave equivalent).

rSR' complex in leads I, V5 or V6 (the S is a Q-wave equivalent

occurring in the middle of the QRS complex)

RS complex in V5-6 rather than the usual monophasic R waves

seen in uncomplicated LBBB; (the S is a Q-wave equivalent).

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