Large Transmural STEMI with Myocardial "Rupture" of Ventricular Septum

A man in his 60's presented after 4 days of chest pain, with some increase of pain on the day of presentation.  Exact pain history was difficult to ascertain.  There was some SOB.  He had walked into the ED (did not use EMS).  Here is his ECG:There is atrial fibrillation at a rate of 95.  There is Right Bundle Branch Block with a QR particularly noted in V1-V3 (no rSR',  as there is an initial Q-wave diagnostic of infarction in the anterior wall and septum).  The Q-waves extend to V5 and are very wide (80 ms in V2).  There are also inferior Q-waves which can mimic a left anterior fascicular block, as they result in left axis deviation.  There is rather massive ST elevation, and this is not only anterior but inferior (see analysis below).   The end of the QRS is best seen in lead V1 (and results in a QRS duration of 176 ms).  If one draws a line down to lead II across the bottom, one can find the end of the QRS in lead II.  From there, one can find the end of the QRS in all leads. This analysis shows that there is ST elevation after the end of the QRS in leads II, III, and aVF, and reciprocal ST depression in aVL.  Thus, this is both an anterior and inferior STEMI.How old is this antero-inferior STEMI?  Could it be acute (vs. subacute or days old)?  Although the patient has had pain for 4 days, could the artery have fully occluded only within hours?  Very unlikely.  Although acute anterio...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs