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  • The ECG demonstrates a sinus mechanism with a complete RBBB pattern (QRS duration of >=120 ms, wide S waves in Lead 1, aVL and V6 together with a predominant wide R wave in V1 This may present as a monophasic R wave or as an rSR' (r wave followed by an S wave and a second R wave)  
    - Q waves in the inferior leads point to a prior inferior wall MI and the presence of ST segment elevation suggests that this infarction is acute or recent. The history of chest pain and a recent normal ECG reinforce this.
    - An associated decrease in R wave voltage suggests that there is loss of lateral forces as a result of an associated lateral MI.
  • A complete LBBB pattern would have created a monophasic R wave in lead 1, avL and the lateral leads with a small r and deep-wide S waves in V1.
  • It is true that an S1-Q3 pattern may occur in patients with acute pulmonary embolism. However, they usually do not have associated characteristics of the inferior wall MI and complete RBBB pattern, as seen in this case.
  • Patients with an inferior wall MI and associated posterior wall MI have prominent R waves in V1. However, in this case, the R wave in V1 is due to the complete RBBB with a QRS duration that exceeds 120 ms.
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