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There were many comments that it was too late for thrombolytics or that this signified an LV aneurysm, not acute MI. See my formula for differentiating anterior LV aneurysm (that is to say, persistent ST elevation after old MI) from acute anterior STEMI. This is my response: "This is definitely acute or subacute. It is not chronic.
Are you confident there is no ischemia? Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? These are all findings that can be expected with left ventricular aneurysm.
Persistent ST elevation 3 days after a nearly transmural MI portends possible LV aneurysm. It is very unlikely to be LV aneurysm morphology when the ST elevation is so high and the T-Wave inversion is so deep. The patient continued to have ischemia after PCI, and in fact had an episode of polymorphic VT shortly after while in the ICU.
This transmural ischemia, but not necessarily completed infarction (yet). See more images of this case at Gopal's Spectral CT Blog: It's all about confidence With continued symptoms, an elevated troponin, and no other explanation, this is acute MI with ongoing ischemia until proven otherwise.
If you still have not read it, I strongly recommend that you read the following article on the diagnosis of "posterior" MI: Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia), by Meyers HP et al. J Am Heart Assoc. 121.022866.
Look for Vascular Etiology -- think of these while doing H and P: --Bleeding: ruptured AAA, GI bleed, ruptured ectopic pregnancy, other spontaneous bleed such as mesenteric aneurysms. Evidence of acute ischemia (may be subtle) vii. starts at end of article on p. Left BBB vi. Pathologic Q-waves viii. LVH or RV d.
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