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Case Report

New Right Bundle Branch Block as a Criterion

for Emergent Coronary Angiography
Jonah M. Pozen, Anit K. Mankad1,2, John T. Owens1, Ion S. Jovin1,2

Departments of Internal Medicine and Cardiology, 1Virginia Commonwealth University Health System, 2Hunter Holmes
McGuire Veterans Administration Medical Center, Virginia, USA

Abstract
Context: ST-segment elevations in two or more contiguous leads or new left bundle branch block (LBBB) on electrocardiography (ECG)
in a patient with acute onset chest pain are diagnostic criteria for acute myocardial infarction (AMI) and generally warrant urgent coronary
angiography and cardiac catheterization. However, the significance of new right bundle branch block (RBBB) without other acute ECG changes
is unclear and is currently not considered a criterion. Case Report: We present a patient with chest pain, positive biomarkers of myocardial
necrosis and isolated new right bundle block on ECG. He was diagnosed with AMI but did not undergo urgent reperfusion therapy in the
absence of ST-segment elevations or new LBBB. However, angiography ultimately demonstrated complete coronary occlusion. Conclusion:
The established criteria for emergent catheterization may prove to be more sensitive with the inclusion of the presence of new RBBB on ECG.

Keywords: Cardiac catheterization, coronary angiography, myocardial infarction, percutaneous coronary intervention, right bundle branch block
Address for correspondence: Dr. Jonah Pozen, Department of Internal Medicine, Virginia Commonwealth University Health System, Virginia, USA.
E-mail: jonah.pozen@vcuhealth.org

Introduction reperfusion therapy because he did not meet current

guidelines for emergent intervention.
ST-segment elevations in two or more contiguous
leads or new left bundle branch block (LBBB) on
electrocardiography (ECG) in a patient with acute
Case Presentation
onset chest pain are criteria for acute myocardial The patient was a 67-year-old Caucasian male with a
infarction (AMI) and generally warrant urgent coronary history of hypertension and tobacco abuse, who presented
angiography and cardiac catheterization.[1] While it with the complaint of right-sided chest pain that he
has been demonstrated that the co-existence of bundle experienced while mowing his lawn earlier in the day. He
branch block and AMI confers a worse prognosis described the pain as dull, rated 7/10, and radiating to his
than AMI without a conduction abnormality,[2,3] the right shoulder and jaw. He denied associated palpitations,
significance of new right bundle branch block (RBBB) dyspnea, diaphoresis, dizziness, or nausea. With rest, the
without other acute ECG changes is unclear and pain improved but did not resolve. He took aspirin 325 mg
currently not a part of the diagnostic criteria. We present once prior to the presentation.
a patient with chest pain and isolated new right bundle
block who was ultimately diagnosed with an AMI with
complete coronary occlusion, but did not undergo timely This is an open access article distributed under the terms of the
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DOI: How to cite this article: Pozen JM, Mankad AK, Owens JT, Jovin IS.
10.4103/1947-2714.172849 New right bundle branch block as a criterion for emergent coronary
angiography. North Am J Med Sci 2015;7:569-71.

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Pozen, et al.: New RBBB and acute MI

On initial evaluation, he reported the pain was Discussion

4/10, which subsequently resolved with sublingual
nitroglycerin. He was noted to have elevated cardiac Patients who present with acute-onset chest pain
enzymes (troponin 3.18, creatine kinase (CK)-MB 29.1), need to be rapidly triaged in order to maximally
and a new RBBB on ECG [Figure 1]. He was given a preserve viable myocardium and limit mortality
clopidogrel loading dose, metoprolol, started on an in the cases of coronary artery plaque rupture and
intravenous infusion of heparin, and admitted for subsequent occlusion.[4] At this time, the ECG criteria
further monitoring and a coronary angiogram and to determine which patients require emergent cardiac
cardiac catheterization. His cardiac enzymes continued catheterization and possible emergent percutaneous
to rise and peaked 6 h after admission (troponin 6.39, intervention include ST-segment elevations in two or
CK-MB 33.3). In addition, he required the administration more contiguous leads or new LBBB.[1] The reason for
the latter is because, with an LBBB, ST-segments and
of intravenous nitroglycerin for recurrent chest pain.
T-waves tend to be shifted in discordant directions,
On hospital day 2, he underwent cardiac catheterization which may either mimic or mask an ST-segment
elevation. This does not hold true, however, in RBBB,
and coronary angiography, where he was found to have
and so this has not been traditionally used as a criterion
100% proximal occlusion of his right coronary [Figure 2].
for emergent cardiac catheterization. However, RBBB
Two drug-eluting stents were placed, with subsequent
may in fact mask subtle ST-segment elevations in the
TIMI 3 flow.
anterior leads (V1-4) due to secondary repolarization
changes resulting in the depression of ST-segments
On hospital day 3, the patient remained asymptomatic
after the rSR′ deflection. This may falsely depress the
and was discharged with lisinopril, metoprolol,
ST-segments below the threshold recommended to
atorvastatin, aspirin and clopidogrel. He was
formally diagnose an ST-segment elevation. In fact, a
encouraged to stop smoking and instructed on a heart-
retrospective analysis by Widimsky et al. of patients
healthy diet and exercise program.
presenting with AMI found that 47% of ECGs with
RBBB failed to demonstrate ST-segment elevations.
When seen 2 months later in outpatient cardiology clinic, [5]
Of those patients, 67% were subsequently found to
the patient reported compliance with his medications
have TIMI flow 0-2.
and denied any recurrence of symptoms.
Beyond the diagnostic limitations due to RBBB, the
HERO-2 trial demonstrated that the co-existence
of RBBB and acute anterior MI confers a 3-4 times
higher 30-day mortality than anterior MI without a
conduction abnormality.[2] Results also indicate that it
is the width of the QRS complexes, and not the degree
of ST-segment elevations that correlate with 30-day
mortality.[6]

Figure 1: Electrocardiography (a) Prior to presentation and (b) On

presentation, the latter demonstrating an isolated new right bundle Figure 2: The right coronary artery is completely occluded in the
branch block proximal segment (arrow)

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Pozen, et al.: New RBBB and acute MI

With regard to chronicity of RBBB, data indicate Conflicts of interest

that new onset (or presumed new, when prior ECG There are no conflicts of interest.
data were unavailable) should be treated as a more
emergent finding than old. Data by Widimsky et al.
demonstrate that new RBBB is associated with a higher References
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AMI.[5] ACCF/AHA guideline for the management of ST-elevation
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Financial support and sponsorship Importance of QRS duration and early ST-segment resolution
Nil. after fibrinolytic therapy. Circulation 2006;114:783-9.

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