This 67-year-old man presents to the respirology clinic for routine follow-up. He has known COPD in the context of a 60 pack-year smoking history, and was recently started on home oxygen:

• Sinus rhythm
  
• Right bundle branch block plus right ventricular hypertrophy (RBBB and RVH)
  

The echocardiogram of this patient demonstrated pulmonary hypertension (PA pressure of 80 mmHg), and right ventricular dysfunction. The criteria for right bundle branch block plus right ventricular hypertrophy are present: right axis deviation and R or R1 in V1 and/or V2 = 15 mm. or greater. The presence of right axis deviation in very important, as the presence of a tall R or R’ in the right chest leads is not uncommon in patients with RBBB with no evidence of right ventricular hypertrophy. In the absence of clinical information, the possibility of left posterior fascicular block (LPFB) + RBBB (bifascicular block) would have been be considered in the differential diagnosis. However, the patients clinical history strongly favors RVH.