Acute chest pain in a patient with LVH and known coronary disease. What does the ECG show?

A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain.Here is his ED ECG:What do you think?There is a flat and downsloping ST segment in V2 and V3.  This could be due to posterior OMI.  Is there an old ECG for comparison?Here is the most recent previous ECG:Indeed, there was some normal ST elevation in V2 and V3, discordant to a relatively deep S-wave which could be due to some LVH.Here is another previous ECG:So it looks like a posterior OMI.2 years prior he had an angiogram which showed 90% proximal stenosis of the circumflex.  It seems that this was probably the infarct vessel.At this point, I was quite certain that this was a posterior OMI. We initiated " Pathway B " , (pathway A is cath lab activation; pathway B is to consult cardiology about possible cath lab activation).  Appropriately, they recommended IV NTG and cath lab if that was not successful.Here is the Queen ' s interpretation as submitted to the telegram bot; she does not have the benefit of comparing with an old one:But when I put it through the PM Cardio app, which is now available in Europe, she says OMI with low confidence.The pain did not resolve with NTG, and so he went to emergent angiography:1. Left main: no obvious stenosis.2. LAD: severe in-stent restenosis in the mid (80%) and distal (90%)segment and diffuse disease distally.3. D1: severe (90%) de-novo stenosis in the mid to distal segment.4. Ramus...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs