A 66-year-old man is admitted for investigation of angina. 5 weeks earlier he had been in another hospital with an acute myocardial infarction. After discharge he complains of frequent angina on mild to moderate exercise:

• Junctional tachycardia, 110/min
• Left anterior fascicular block

Comment:  Notice the retrograde P waves (pseudo-S-wave in the inferior leads and pseudo-R-prime  in V1). The patient had suffered from a q-wave inferior myocardial infarction 5 weeks earlier. The small r waves in the inferior leads caused by the left anterior fascicular block may mask the QRS changes of the inferior infarction.