Anterorlateral STEMI? Old Anterior MI? But cath shows RCA thrombotic stenosis.

This case is from a frequent contributor, Brooks Walsh.  With additions and edits by me.A 68 year-old man had been having chest discomforts intermittently for the past 2 weeks. About 18 hours prior to presentation, his pain began to worsen. He developed nausea, and 911 was called after he vomited once. EMS obtained an ECG:There is subtle ST depression in II, III, and aVF. There is ST elevation in V2 – V5, with Q waves in V2 – V4.  This is all but diagnostic of anterior MI.Is it acute? subacute? Old MI with persistent ST elevation?EMS requested cath lab activation. The patient was given nitroglycerin 3 times, and his discomfort resolved completely before arrival to the ED. The ECG was repeated at that point:The ST elevation in V2-V5 appears more pronounced, otherwise no significant changes.Is this acute or chronic ST-segment elevation?Concern was raised by cardiology that, given the duration of symptoms, as well as the anterior Q waves, that the ECG changes could reflect a chronic pattern of persistent ST-elevation (STE) following previous MI; aka “left ventricular aneurysm” (LVA). Emergent angiography for an NSTEMI might not serve an elderly patient well, they emphasized. Quite true!However, there are elements of the ECG that suggest that, even if she does have an old anterior MI, she also likely has superimposed features of an acute anterior STEMI. First:Specifically, the anterior T-waves are relatively tall, compared with the QRS complexes. In both V2 and ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs