Is this acute STEMI? LV Aneurysm? Would you give Thrombolytics?

Recently I posted a case describing "Acuteness" on the ECG and how to assess whether it is too late for reperfusion, especially thrombolytics.This case was recently posted by Tyron Maartens on Facebook EKG club (he agreed to let me post it here), with the following clinical information:"42 year old male with two weeks of intermittent chest discomfort, awoke 4 hours prior to this ECG with a more severe, heavy chest pain (5/10). Self-medicated with 600 mg Ibuprofen and 750 mg Paracetamol (no change) prior to driving to the ED. BP 112/80, SpO2 100%. Patient appears only slightly anxious. No risk factors, leads a healthy lifestyle. Unremarkable physical examination. Not a difficult ECG per se, but what's your management plan? PCI is not an option."Would you give thrombolytics? We all know that some other information would be helpful, but he did not offer it.So let's just go with what we have.See my answer below.There were many comments that it was too late for thrombolytics or that this signified an LV aneurysm, not acute MI.This is my response:"This is definitely acute or subacute. It is not chronic. See my formula for differentiating anterior LV aneurysm (that is to say, persistent ST elevation after old MI) from acute anterior STEMI. There is no question that this benefits from immediate PCI. See this full text link to an article from JAMA on PCI in patients who present at 12 to 48 hours. As for thrombolytics, that is a bit riskier. I think the ECG supports an occ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs