Here is the conclusion to an unusual case of right bundle branch block.
Let's take another look at the 12-lead ECG.
This 12-lead ECG shows acute anterior STEMI in the presence of right bundle branch block, but you really need a trained eye to see it.
We talk a lot about the "rule of appropriate T-wave discordance" with bundle branch blocks. What makes this case difficult is the fact that the T-waves are appropriately discordant.
However, the J-points are concordant in leads V1-V4!
If you look carefully you will see that the point at which the QRS complex turns into the ST-segment (the J-point or "junction" point) is elevated above the isoelectric line.
That's abnormal for right bundle branch block. In fact, if the J-point isn't isoelectric in the right precordial leads it should be slightly depressed (in the same direction as the T-waves).
Lead V4 looks the most abnormal.
If you're still having doubts, consider that Q-waves are present in leads V1-V4.
That's what Tomas Garcia, M.D. means when he says to "consider the company" that any ECG abnormality keeps.
Finally, let's look at leads III and aVF.
We are forced to assume that these are reciprocal changes even though the terminal QRS is isoelectric. You'd need an old ECG for comparison to know for certain.
This patient was in fact suffering LAD occlusion.