A 56-year-old diabetic man with no history of chest pain is in the emergency department in congestive heart failure:

• Sinus tachycardia, 120/min
• Nonspecific intraventricular block
• Possible septal infarction, age undetermined

Because of a QS pattern in V1 and V2  and a tiny r wave in V3 a previous septal infarct should be considered in this diabetic patient, even in the absence of chest pain. Patients with non specific intraventricular conduction block may have poor R wave progression in the chest leads in the absence of infarction. Further investigation is obviously required.