H/o MI and stents with brief angina has this ED ECG. And what is Fractional Flow Reserve?

A middle-aged man complained of 15 minutes of classic angina that resolved upon arrival to the ED.Here is his initial ECG:What do you think?There is sinus rhythm with RBBB and possible LPFB (see Dr. Grauer's detail below).  There is ST elevation in II, III, and aVF, and reciprocal ST depression in aVL.  And there are Q-waves in both inferior and lateral leads.  So this is indeed diagnostic of myocardial infarction.Should we activate the cath lab?No! Not immediately, at least, because this is NOT diagnostic of ACUTE (occlusion) myocardial infarction (Acute OMI).  We need to do some more investigation.Although diagnostic of MI, it is highly suspicious for "Old inferior MI with persistent ST Elevation " or " inferior aneurysm morphology " because of the well-formed Q-waves and the flat T-waves.Inferior aneurysm can look a lot like ACUTE inferior MI because it does not usually have QS-waves (as anterior LV aneurysm usually does); instead, inferior aneurysm usually has QR-waves, which in inferior MI are often seen in BOTH acute and old MI.  QS-waves imply no remaining deplorizing forces toward the overlying lead. To repeat: in contrast, anterior aneurysm is much more easily distinguished from acute MI due to the QS-waves.I immediately looked for old charts, which were only available from another hospital, and an old echo confirmed inferior " akinesis " (which may also have persistent ST elevation).  A true ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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