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He has a history of STEMI and heart failure. The only alternative is old inferior MI with persistent ST-Elevation, or inferior aneurysm morphology. Inferior Aneurysm morphology is incredibly hard to differentiate from Acute OMI, but you should suspect it whenever there are well-formed inferior Q-waves. He had a prehospital ECG.
50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus.
There are no Q-waves to suggest old inferior MI, or inferior aneurysm as the etiology of the ST Elevation. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. Truly, the Marquette 12 SL algorithm correctly identifies this STEMI. See reference and discussion below.
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