What, besides large anterior STEMI, is so ominous about this ECG?

This article by Widimsky illustrates the danger of this finding:See these cases:Chest Pain and Right Bundle Branch BlockTreatments:1. Aspirin 325 mg2. Ticagrelor 180 mg3. Atorvastatin 80 mg (small studies support this)4. Heparin bolus5. Fluid challenge6. Because cardiogenic shock is likely to get worse, even after reperfusion (because myocardial stunning lasts many days), we intubated the patient.7. Vecuronium paralysis8. Ketamine sedation (to avoid affecting hemodynamics)9. K replacement.10.  Should have cardioverted, but did notBy this time, the cath team was ready.A proximal LAD thrombotic occlusion was opened.  Here is the post-reperfusion ECG:Sinus rhythm at a rate of 117. Uncertain if conversion was spontaneous, or done electrically in the cath labRBBB and LAFB persist (not a good sign).ST elevation is greatly improved (a good sign), though still very elevated (not a good sign).There is terminal T-wave inversion, an early sign of reperfusion.A balloon pump was placed.Here is the ECG the next day:Q-waves and poor R-wave progression.  RBBB and LAFB are gone.  (A good sign).Highest troponin I was extremely high at 230 ng/mL at 10 hours after arrival.Echo showed anterolateral wall motion abnormality and EF of 35%.In spite of maximal supportive therapy, balloon pump, and persistently open arteries, the patient succumbed to cardiogenic shock 5 days later.Learning Points:1. Cardiogenic shock due to STEMI has very high mortality even if the artery is opened....
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs