A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?

A 90-something year old woman presented with an acute mild stroke.She had a routine ECG as part of her workup:What do you think?This was shown to me in real time.I thought it had to be an inferior-lateral-posterior OMI.  But the patient had no symptoms.  Later, she did admit to some vague chest discomfort, but that could be due to the power of suggestion.The one strange thing that I noted at the time is that there is no reciprocal ST depression in aVL.  This is extremely unusual in inferior OMI, even if there is simultaneous STE in V5-6.We studied this: In this paper on the importance of lead aVL for diagnosis of inferior OMI, we reported that all 33 patients with inferolateral MI, as manifested by STE in V5 and V6, still had ST depression in aVL.  V5 and V6 are caudal to aVL and so an inferior ST vector towards lead aVF is also slightly towards V5 and V6 but away from aVL!!  So V5 and V6 will have some ST elevation while aVL has ST depression.  Thus, even inferolateral MI has reciprocal ST depression in aVL.  The cath lab was activated.First trop = 42 ng/L (URL for women = 16, but for a 90-something, it is likely that the URL is much higher)The angiogram was negative!Peak trop 62 ng/L (would be very low for acute OMI)Next AM ECG:Still with very ischemic looking T-waves.Later, I found old ECGs:5 month prior in clinic:V5 and V6 look like OMI9 months prior in clinic with no chest...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs