Right Bundle Branch Block with Q Waves in V1 and V2

Journal of Insurance Medicine Volume 2 I, No. 2 I £89Interesting ElectrocardiogramRight Bundle Branch Block withQ Waves in V1 and V2M. Irend Ferrer, M.D.Consultant in Cardiology Metropolitan Life Insurance CompanyProfessor Emeritus of Clinical Medicine, College of Physicians and Surgeons, Columbia UniversityConsultant Electrocardiographer, Presbyterian Hospital, Columbia Presbyterian Medical Center, New York, N.Y.A review of this tracing of a 79-year-old man, taken in a preoperativeroutine evaluation when he entered the hospitalfor surgery, allows us to consider the evaluation of completeRight Bundle Branch Block (RBBB) in asymptomatic patients.The rhythm in the ECG is normal sinus at 75/min. with aprolonged PR interval (0.25 sec. in lead II). There are alsoatrial premature beats (APC), some of which are blocked andfollowed by a pause and a junctional escape beat (whoserhythmicity is 43/min.). Such a sequence is marked with anarrow in V4. A conducted APC is marked in lead II.The IV conduction defect is of more serious nature. Note thatthe tracing shows complete RBBB with a marked left axisdeviation (axis = -68 °) indicating left anterior fascicularblock (LAFB). Of special importance in this record is thepresence of wide Q waves in V1 and V2 permitting thediagnosis of anteroseptal myocardial infarction. In summary,there is tri-fascicular block (RBBB, LAFB and prolonged PR).The etiology of this IV conduction defect is the anteroseptalmyocardial infarction. Thus coronary artery disease is present.Were this record to be submitted for insurance purposes therewould be little problem. However, the evaluation of anelectrocardiogram showing only RBBB has undergoneconsiderable change in recent years. A recent review of thissubject from the Gerentology Research Center, NationalInstitute on Aging, National Institutes of Health 1 emphasizesfirstly that RBBB does not constitute a homogeneous clinicaldisorder, and prognosis essentially depends on the natureand extent of the underlying etiology. The study was made(on men only) on long term prognosis (8.4 years) andaddresses the question whether RBBB of itself presagessubsequent cardiovascular disease and mortality. They foundthat cardiovascular morbidity and mortality are not increasedin asymptomatic men with RBBB as compared to matchedcontrols. The benign nature of simple RBBB is thusreaffirmed. However, although no increased risks were notedin uncomplicated RBBB, if marked left axis deviation withor without a prolonged PR interval appeared in later life thereappears to be the likelihood of primary conduction systemdisease (calcification and sclerosis locally in the IV septum).This condition is age-related. Nevertheless, it is a benigndisorder in no way related to coronary disease.The solution in this tracing is simple as coronary disease isclearly present.~ The evaluation of uncomplicated RBBBrequires considerable investigation in order to avoid anyexcess rating.ReferenceFleg, J.L.; Das, D.N.; LaKatta, E.G. Right Bundle Branch Block: Long Term Prognosis in Apparently Healthy Men. J. Am. Coll. Cardiol., 1(3)887-892, 1983.ErratumRegrettably a typesetting omission and an error occurred in the text of Dr. Ferrer’s Interesting Electrocardiogram in the previousissue of JIM: Pre-excitation and Cardiomyopathy (with a note on Myocardial Bridges), Vol. 21, No. 2, 1989 page 49.In the second paragraph, the sentence beginning on line 20 should have read: "Since there is no WPW pattern present (whichdistorts the record) the ST-T abnormalities in Leads II, III, AVF, and V3-V6 emerge as evidence of underlying myocardial disease.The electrocardiogram of 8/1/72 (on no digitalis) differs very little from that of 4/14/83 taken years later."131 m

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