Can misplaced EKG leads show an incorrect Left Posterior Fascicular Block?

Stats:
- 31 (almost 32)
- male
- 6'0
- 221lbs.

I have a Complete RBBB, diagnosed for the first time about 10 months ago. At that time I had an EKG plus an ECG, plus a pulmonary function test. (PFT.) The PFT showed some minor abnormalities, but nothing indicating problems, at least not according to my doctor. (I can post those results if necessary. The common mention, though, over the past few years has consistently been, "Your lungs are huge. And very powerful. Are you a diver?" I'm not, though I was a tuba player.)

Since then I started walking/running 3-10 miles per day. I also lost 25lbs.

Last month I went into the doctor's office after my wife was able to hear my heart beat through my mouth. EKG then showed no change from the previous. "Am I looking at the same one?" The doctor asked. "This is identical." Still, he sent me to get a stress test. Cardiologist agreed with his recommendations and his sentiments, noting that the stress test was to make sure that all the bases were covered.

Had an ECG monday. Everything normal. In fact, things had gotten better than last year: My aortic root went down from 3.5cm to 3.1cm, for example, and the imaging of the right ventricular volume showed normal size (previously it was at 6.0cm, borderline normal/enlarged according to their measurements).

Today I had my treadmill stress test. Went 15 minutes without a problem, and stopped only when my heart reached 170/80 (and I was a bit out of breath). Prior to that, when laying down, I'd gotten an EKG (I think it was a 7-lead? 9-lead? She didn't do the legs, for example.) The EKG showed not just an RBBB, but also a Left Posterior Fascicular Block.

Previous EKG's - P/QRs/T Axis = 56/35/14. (Done exactly 1 month ago)
Today's EKG - P/QRs/T Axis = 96/168/34.

(I would offer more numbers, but I don't have a copy of today's EKG.)

Other than this, (and the pre-existing RBBB) everything was perfect. Despite this, the doctor said my prognosis was great, and that I could see an Electrophysiologist if I'd like. (I said yes. The appointment is for the 18th.)

My question: Could there have been lead placement issues at play here? If so, what? Today's EKG looked very different to the ones I've had previously. Also, I have a follow up appointment with my cardiologist on the 31st. (Happy Halloween, let's hope!) Should I make the appointment with the EP after the cardiologist? Or should I consult the EP prior to my follow up? And if correct, what could cause this kind of rapid change when all else seemed stable?

I don't think I'm in any eminent danger of death, which is why I don't mind waiting. I guess I just want to know what would be best, for the sake of information (and cost).

=====

For reference, here were my previous EKG numbers:

P/PR: 124/152ms
QRS: 172ms
QT/QRc: 420/463ms
P/QRS/T Axis: 53/35/14
Heart Rate: 73BPM

Sinus Rhytm Normal
Consider RVH
- R > mV in V1
- R/S > 1 in V1
RBBB
- QRS = 172ms
- RSR' in V1
S>30ms in I V5 V6
marked right-pericordial repolarization disturbance secondary to RBBB
- Large negative T in V2
- with negative T in V3*
Abnormal EKG

*Note: Discussed this with the doc. She said it was a placing issue, the lead was a bit higher/lower than it should have been. The patterns, she said, still held up to the previous results.

[itdood]

It looks like you doctor already answered the question, or am I missing something?

[gnorb]

Thank you for answering. Sorry if I was not clear.

Today's doctor did not address the LPFB issue encountered prior to the Treadmill Stress Test, which was the question at hand. *I* was the one who asked whether it might have been a lead issue. *I* was the one who pointed it out and said, "This looks nothing like the others.

He said, "Maybe it was a lead placement issue, but here's an appointment with an EP to calm your fears." The feeling I got was one of him saying "This is right, and you're scared because of this highly technical stuff. I'm not going into detail, so go talk to someone else."

My questions are:
1) How likely is it that a placement issue would cause that kind of deviation difference?

2) Under what conditions (leads-wise) could it happen? What needs to be screwed up to create that kind of deviation difference? How many leads in the wrong place?

3) Could anything cause that kind of progression--from RBBB to RBBB+LPFB--in that period of time outside an error or MI? (I have been exercising more vigorously as of late. My heart's felt great, as has my breathing.)

4) Might it be most beneficial to wait until after my cardiology follow up to see the EP? (I've never been to one, so I have no idea what to expect.)

Side items to note:
- I had Gastroparesis before due to a post-viral illness.
- I have mild (but symptomatic) eosinophilic esophagitis, as well as mild peripheral eosinophilia.

Thank you for your time.

[is_something_wrong]

1) During stress test they sometimes don't use standard 12 lead EKG's. Instead of the usual "V1-V6" precordial leads they sometimes use something named CM1-CM6 (I think).
This is probably to make the EKG more sensitive of ischemia. If that's the case, the results can't be compared regarding QRS axis.

I also see that your P axis (atrial axis) is deviated 40 degrees to the right. That supports the theory about lead placements. Also, axis is calculated by using the limb leads (electrodes on your legs and arms) if they weren't present, the calculation may not be correct.

2) see 1.

3) Anything is possible but not likely. I think I've read an answer from dr. Richardson at Allexperts concerning what may cause LPFB or LAHB some time ago, but I can't seem to find it. You can get those blocks without an MI. I didn't even know healthy people in their low 30s could get MI, especially without noticing it. It would also show signs on EKG.

4) The EP will probably analyze your EKG's, make sure to bring the ones you are worrying about. I can't see why you should change your appointment.

Trust your cardiologist. He knows more about this than you and me :) I think we all need to accept our role as patients better.