What happens when a patient with LAD OMI does not go immediately to the cath lab?

This patient was extremely elderly, and although the diagnosis was recognized, she did not go to the cath lab for reasons related to age and patient/family choice.Nevertheless, there is a lot to learn from the ECGs.I was shown this ECG without any information:QTc = 431 msWhat was my response?I immediately said:" Acute LAD occlusion. OcclusionMI (OMI) "  (And sinus rhythm with a PVC.) (Not quite a STEMI, but same effect.)Why did I diagnose LAD occlusion?There isST elevation in V2-V4 that does not quite meet " STEMI criteria. "  Is it normal ST elevation?  No!  How do I know?  First, there is reverse R-wave progression.  The R-wave in V3 is smaller than the R-wave in V2.  Thus, there is reverse R-wave progression, and even a Q-wave in V4. This never happens in normal ST elevation. There arehyperacute T-waves in V2-V4.The 4-variable formula can be used: http://hqmeded-ecg.blogspot.com/p/rules-equations.htmlAlso see free apps:iPhone:" SubtleSTEMI "Android:" ECG SMITH "www.mdcalc.com: https://www.mdcalc.com/subtle-anterior-stemi-calculator-4-variableHere, the QTc = 431STE60V3 = 1.5RAV$ = 4QRSV2 = 13.5.Formula value = 20.89, which is much higher than the cutpoint of 18.2 and makes this LAD occlusion until proven otherwise.You might think it is " Old MI with persistent ST Elevation, " or " LV aneurysm " morphology.  That is a reasonable thought, but we have shown that if there is one lead of V1-V4 with a T/QRS ratio gr...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs