This ECG was obtained in an 80-year-old male with PAD and prior DVT, now with chest pain, dyspnea, diaphoresis. The tracing shows a sinus rhythm at 89 BPM with convex upward “tombstone” ST elevation in leads II, III, aVF, and associated severe ST depression in leads V1-V4. These findings are consistent with STEMI involving the inferior and posterior walls of the LV. Also a borderline NSIVCD is present, with QRS duration = 111 ms (best appreciated in lead V1); scoring for this would likely be given neutral credit on the Boards. Although Q waves have not yet developed inferiorly, nor have prominent R waves developed in leads V1-V3, the repolarization abnormalities are diagnostic of acute inferior and posterior MIs. Scoring for ST-T changes of acute myocardial injury is optional in this setting, and doing so would likely be given neutral credit on the Cardiology Boards. Possible left atrial enlargement is present in V1 but since the criteria are borderline, scoring for LAE would be given neutral credit. This patient was taken to urgent coronary angiography/PCI, during which an acutely occluded proximal segment of a “super-dominant” RCA with a large posterolateral artery was recanalized and stented.

Correct Answers:

• Sinus rhythm +2.
• Left atrial enlargement 0.
• Nonspecific intraventricular conduction disturbance (IVCD) +0.
• Inferior MI, acute or recent +4.
• Posterior MI, acute or recent +4.
• ST-T changes suggesting myocardial injury 0.
• All others -1.