Flipping of the T-waves in the precordial leads suggests that the MI has evolved. The presence of broad complex escape rhythm with prominent q-waves and ST-segment elevation indicates acute MI as the etiology. This case highlights the importance of recognizing the ECG changes associated with acute MI in patients presenting with complete heart block and the utility of Cabrera’s sign in diagnosing anterior wall MI in the presence of left bundle-branch block or right-ventricular paced rhythm. Right-ventricular paced rhythm with left bundle-branch block morphology and left superior axis showing prominent notching (arrows) on the ascending limb of S wave in V2, V3, V4, and V5 (Cabrera’s sign). Percutaneous coronary intervention with stenting was done, and there was restoration of flow without a recovery of the complete heart block.įigure 4. A temporary pacemaker was inserted, and the coronary angiogram showed complete thrombotic occlusion of the proximal left anterior descending artery ( Figure 3). The patient was diagnosed to have acute anterior wall MI, with complete heart block and cardiogenic shock. Prominent inverted T-waves in the precordial leads indicate the evolution of MI and suggest that the presentation is relatively late. The “qRBBB” pattern in leads V1 and V2 with ST-segment elevation in precordial leads is suggestive of acute anterior wall myocardial infarction (MI). Extremely slow rates and wide QRS complexes suggest that the block is infranodal. The presence of atrioventricular dissociation is diagnostic of complete heart block. Flipping of T-waves in leads V2 through V6 suggests evolved myocardial infarction.

Pathological q-waves in V1 and V2, and ST-segment elevation in V1 through V5 are suggestive of acute anterior wall myocardial infarction with lesion localization in proximal left anterior descending artery. AV dissociation (arrows) with a slow and wide QRS escape.

Customer Service and Ordering Informationįigure 2.

Stroke: Vascular and Interventional Neurology.

Journal of the American Heart Association (JAHA).

Circ: Cardiovascular Quality & Outcomes.

Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB).

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