The ECG was recorded from a 42 year old man 48 hours after admission to the coronary care unit. Both his father and elder brother had suffered a myocardial infarction; he smoked twenty cigarettes a day.
There are pathological Q waves in leads V2 and V3. There is loss of R wave in the precordial leads- no R wave appears until V4 and this is smaller than the R wave in V5 (it would normally be expected to be larger). The ST segments show the raised appearance typical of acute myocardial infarction in leads V2 and V3 and the T waves are becoming inverted in these leads at this stage. Established T wave inversion is present in leads I, II aVL and precordial leads V4, V5 and V6.
The ECG shows the changes of recent anterior infarction affecting the interventricular septum (as denoted by the changes in VI, V2 and V3) and adjacent left ventricle (as denoted by the changes in V4). Subsequent investigation showed that the left anterior descending coronary artery was occluded. Clinically an ECG like this indicates a recent, but not in the last few hours myocardial infarction. These patients should go for PCI, but there may be less urgency in doing so as compared to the hyper and acute changes of AMI seen in other cases. The patient should be managed as an ACS patient with aspirin, antiplatelet agents and low molecular weight heparin according to local guidelines.