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A 92-year-old man presents with gradually worsening dyspnea on exertion that has progressed to exertional chest fullness. He is asymptomatic on arrival, his ECG shows a bifascicular block unchanged from prior, and his high-sensitivity troponin is 9 ng/L on arrival and unchanged at one hour — completing the rule-out under a standard hs-troponin protocol.

Think it through first

The protocol says he is ruled out. Decide whether you would send him home.

The ECG

12-lead ECG for this case showing sinus rhythm with a bifascicular block pattern
Review the 12-lead ECG above, then answer the questions below.

Case Quiz

1. His ECG shows a right bundle branch block with left anterior fascicular block, unchanged from a prior tracing. What does that tell you?
2. His high-sensitivity troponin is 9 ng/L on arrival and unchanged at one hour. What does that reliably exclude?
3. He is asymptomatic, his ECG is unchanged, and the hs-troponin pathway says “ruled out.” What is the most defensible next step?

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