5 hours of chest pain. How acute is the STEMI?

A male is his 30's with h/o HTN presented after 6 hours of chest pain.  The pain was crushing and substernal, associated with nausea, vomiting, and diaphoresis, radiating to his back, 10 out of 10 in intensity, the "worst pains ever experienced". He described the sensation as "an elephant sitting on chest".  Here is his EKG by EMS:Obvious anterior STEMI with very large T-waves.  Is this consistent with 5 hours of injury?The cath lab was activated prehospital.  Patient received 324 aspirin and 3 nitroglycerin tablets sublingually prior to arrival to the ED with mild improvement of pain. Here is the ED ECG:Very hyperacute T-waves and ST elevation.  Somewhat diminished after Nitroglycerine.Suppose you were at a small hospital that only has thrombolytics.  You have the option of giving thrombolytics or of transferring to a PCI capable hospital.  The Door (small hospital) to Balloon (PCI hospital) time will be 90 minutes.Should you give thrombolytics?It is well known that thrombolytics work best with fresh thrombus, within 2 hours of onset of occlusion (Steg et al., see reference 8 below).  But this patient has had 5 hours of chest pain.However, the ECG shows a very high level of "Acuteness," as demonstrated by 1) the size of the T-wave 2) the amount of ST elevation and 3) the absence of Q-waves.   Hyperacute T-waves are present when there is a large amount of viable, salvageable, myocardium.  As the myocardium infarcts (Q-wav...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs