Question 6.1

This is the ECG of a 74-year-old gentleman who had an out of hospital cardiac arrest. 


1. What are the abnormalities on the ECG?

2. What would your management plan be if the patient makes a good functional neurological recovery? 

[Click here to toggle visibility of the answers]

College Answer

1. Right bundle branch block and left posterior fascicular ( or right axis deviation) block

2. Permanent Pacemaker + Coronary angiography to exclude coronary vascular disease


This is another "what ECG is this?" question, made harder to discuss because the college has removed the ECG from its paper.

... its a bi-fascicular block:

  • RBBB 
    • Wide QRS
    • RSR pattern in V1
    • Wide slurred S waves in I and V6
  • LPFB
    • Right axis deviation (QRS in III is taller than II; lead I and aVL are negative
    • No better explanation for the right axis deviation

This image was stolen from

As all bifascicular blocks, this one out to be managed with a permanent implanted device.


ACC 2008 guidelines are the direct source for all pacemaker-related recommendations.


ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons.