This is Part II of the conclusion to 80 year old male CC: Chest pain. For Part I see Excessive discordance as a marker of acute STEMI in LBBB.
First, let's take another look at the initial 12-lead ECG.
The first thing that catches my eye in this ECG is the strange morphology of the ST-segments and T-waves in the inferior leads (and lead aVL).
Could these be reciprocal changes to an acute anterior STEMI?
This ECG easily meets Sgarbossa's criterion of discordant ST-elevation > 5 mm, but is the ST-elevation excessively discordant when taking into account the depth of the S-wave?
Let's apply Dr. Smith's decision rule (that we learned about in the previous post). Do we see "excessive discordance" in this ECG?
If this isn't evidence enough there are also significant changes in QRS voltage and ST/T morphology between the first and last 12-lead ECG.
Diagnosis: Acute anterior STEMI in the presence of LBBB.
New left bundle branch block is a poor predictor of coronary occlusion (Dr. Smith's ECG Blog)