Subacute STEMI. Should the patient go for emergent PCI, or can he wait until the next day?

This was sent by a very good medical student, who had a very good question.  He wishes to remain anonymous.A 56 y/o male presented with Chest Pain radiating to the left jaw, starting at 8pm the previous night (15 hours prior), which was 10/10 at that time.  He decided to wait it out at home, then presented at around 11 AM, pain now reported at 2/10. Here is the initial ECG (see the patient's previous ECG below for comparison):There is sinus rhythm and new inferior QS-waves with less than 1 mm of inferior ST elevation, and reciprocal ST depression in aVL, and T-wave inversion.  Such T-wave inversion is common not only in reperfusion, but in persistent and prolonged occlusion after formation of Q-waves, especially QS-waves.Here is the patient's previous ECG:This old ECG confirms that the first ECG shows a new MISo this patient has a subacute STEMI.   The initial troponin T returned at 0.47 ng/mL (quite high for Troponin T) and rose from there to 0.81, then 1.96 (typical of a large STEMI).  Whether the troponin continues to rise or not says nothing about ongoing ischemia: it takes time for complete troponin rise and fall even after infarction is completed.  Only the ECG and pain can tell you prospectively whether ischemia is ongoing. The patient was admitted with "NonSTEMI" and did not undergo emergent angiogram and PCI.  He went the next day.This is a nearly completed STEMI (a very advanced subacute STEMI). To call it a Non...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs