Chest Pain in an Adult Male With an Ominous ECG

Can you discern the anomaly in this patient's ECG? What clue(s) does it provide to the underlying pathology?

A 47-year-old man with no previous medical history called 911 complaining of chest pain; EMS treated the patient with aspirin and sublingual nitrates and obtained an ECG (Figure1) at 9:50 am. He was transported emergently to the emergency department (ED) with chest pain described as an aching sensation. The pain was associated with nausea, dyspnea, and diaphoresis and had begun intermittently approximately 5 hours before the 911 call that morning. On ED arrival, the patient was ill-appearing with significant diaphoresis. The examination was otherwise unremarkable. An ECG (Figure 2) was obtained at 10:03 am while management continued.

The high-risk findings noted on the ECG in Figure 2 include which of the following:   

A. ST-segment elevation in lead aVr.

B. Prominent T waves in the right to mid-precordial leads.

C. ST-segment depression in the right to mid-precordial leads.

D. All of the above.

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