An Exhausting Case of “Smoker’s Cough”

ANSWER
The correct interpretation includes sinus rhythm with complete heart block and a junctional rhythm, a rightward axis, and evidence of an anterior myocardial infarction (MI).

Sinus rhythm is evidenced by the regular rate and rhythm of the P waves.

Complete heart block is identified by the atrioventricular (AV) dissociation (QRS independent of the P wave), while the normal QRS duration—despite AV dissociation—confirms the existence of a junctional rhythm.

A positive R-wave axis slightly above the upper limit of normal, as seen with this patient, constitutes a rightward axis.

Finally, the posteriorly directed forces in the anterior precordial leads with poor R-wave progression denote an anterior MI.