Sinus rhythm with left atrial abnormality. Most striking are tall right precordial R waves with pathologic inferior and lateral Q waves giving a "reverse" type R wave progression. There are also ST-T abnormalities in I, aVL, V6. Thus the patient has coronary artery disease (CAD), s/p large infero-(postero)-lateral myocardial infarction (MI) accounting for congestive heart failure (CHF) findings. Recall that differential diagnosis of tall right precordial R waves includes: 1) Normal/positional variants, 2) Right ventricular hypertrophy (RVH) (look for right axis deviation, P pulmonale), 3) Posterior/lateral MI (usually signs of inferior MI, too), 4) hypertrophic cardiomyopathy/idiopathic hypertrophic subaortic stenosis (HCM/IHSS), 5) right bundle branch block (RBBB), 6) Wolff-Parkinson-White (WPW ) variants with posterior/lateral pre-excitation 7) Duchenne muscular dystrophy (young men with myopathy).
