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Randomized clinical studies have demonstrated that tissue plasminogen activator thrombolytic therapy improves functional outcomes. Recently the time window for tissue plasminogen activator thrombolytic therapy has been extended from 3 to 4.5 h after ischemic stroke onset, which will allow more ischemic stroke patients to benefit from this treatment. Healthcare providers should also ascertain whether the ST-elevation myocardial infarction (STEMI) patient has also neurological contraindications to fibrinolytic therapy, including any history of intracranial hemorrhage, significant closed head or facial trauma within the past 3 months, uncontrolled hypertension, or ischemic stroke within the past 3 months (EXCEPT acute ischemic stroke within 3 h). History of prior ischemic stroke greater than 3 months is a relative contraindication. We present a case of tissue plasminogen activator thrombolytic therapy in a 68-year-old Italian man admitted to the Emergency Department with heart failure, ischemic stroke and ST-elevation myocardial infarction. Also this case focuses attention on regression of ischemic stroke symptoms in STEMI patient treated with tissue plasminogen activator thrombolytic therapy.

Changing axis has been reported [1–8] also during atrial fibrillation [9–11] or atrial flutter [12,13]. Changing axis has been also reported during acute myocardial infarction [14–25] associated with atrial fibrillation too [26,27] or at the end of atrial fibrillation [28,29], also during acute myocardial infarction [30,31]. Dissimilar electrocardiographic patterns associated with right bundle branch block have been described [32]. Changing bundle branch block [14,33], new right bundle branchblock [34], rightbundle branchconductiondisturbances [35] and intermittent right bundle branch block [18] have also been reported in literature. We present a case of a right bundle branch block with changing axis at the end of atrial fibrillation in a 57-year-old Italian woman. A 57-year-old Italian woman was admitted to the Emergency Department with an atrial fibrillation. She reported the onset of palpitations approximately 2 h before. The ECG was performed and it showed a right bundle branch block with an atrial fibrillation (Fig. 1). The patientwas admitted to the Cardiology Unit. No pericardial effusion was observed at echocardiographic evaluation. After restoration of sinusal rhythm, the ECG showed right bundle branch block with changing axis and it was confirmed on ECG's surface performed on the following day (Fig. 2). Also this case focuses attention on changing axis.

a Cardiologia Nuovo Presidio Ospedaliero Cutroni Zodda-Barcellona P.d.G(Me), Azienda Sanitaria Provinciale di Messina, Via Cattafi, 98051 Barcellona Pozzo di Gotto, Messina, Italy b Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Italy c Pronto Soccorso Nuovo Presidio Ospedaliero Cutroni Zodda-Barcellona P.d.G(Me), Azienda Sanitaria Provinciale di Messina, Italy