RBBB with STE in I and aVL. Will the angiogram tell you if this ECG represents Occlusion MI or not?

A middle aged male with history of STEMI and stents presented with one hour of chest pain.Here is his ED ECG:What do you think?Analysis: There is sinus rhythm with RBBB.  There is ST Elevation in I and aVL which is discordant to the wide S-wave (a wide S-wave in lateral leads is a feature of RBBB).  There is also some ST depression in lead V3 (inferoposterior OMI is suggested).  There is no R ' -wave in V2 and so one would not expect the typical discordant ST depression and TW inversion that one often sees in V2.  However, V3 does have an R ' -wave, and STD, but the T-wave isconcordantly positive, which is unusual.ST Elevation is supposedly never present at baseline in RBBB.  I say " supposedly " because this is notentirely true.  Many RBBB have some small amount of ST Elevation in I and aVL, discordant to the wide S-wave.  And this ST Elevation is also accompanied by inferior reciprocal ST depression. See examples of this at the bottom, with links.There was a previous ECG from 2.5 years ago:Here there is no ST Elevation.  Thus the STE in the first ECG must be assumed to be OMI for many reasons.1) the patient is high risk2) the symptoms are classic (acute chest pain)3) the ST Elevation meets STEMI criteria4) the ST Elevation is newThe T-wave in V3 is positive here too, but discordant to a wide S-wave (normal).  On the other hand, the upright T-wave in V3 in the first ECG above was concordant to an R ' -wave...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs