A 47-year-old man with several risk factors for coronary artery disease is brought to the Emergency 65 min after onset of severe central anterior chest pain:

• Sinus rhythm
• Anterior injury pattern
• Acute anterior infarction

Comment: The patient received a bolus injection of TNK- tissue plaminogen activator. Chest pain and ST elevation persisted. He underwent coronary angiography that showed a proximal occlusion of the main left coronary artery, that was not suitable for angioplasty.
He was taken to the operating room for urgent bypass surgery. The anterior descending artery received a LIMA graft and an intermediate artery a saphenous vein graft.

The following ECG is recorded in the cardiac surgical ICU 2 hours after the end of the operation:

• Sinus rhythm, 100/min
• ST-elevation, acute anteroseptal infarction

• Sinus rhythm
• Anteroseptal infarction
• T wave abnormality, consider anterolateral ischemia

The patient makes a good recovery and returns to active life without recurrence of chest pain. This ECG is recorded 4 months after the operation, during a reassessment in the cardiac clinic:

• Sinus rhythm
• Septal infarction
• T wave abnormality, consider anterior ischemia

 The 4 tracings are an example of evolutionary ECG changes of an acute anteroseptal infarction.