“STEMI is Acute MI” , and “Acute MI is STEMI” ! This is how we have been taught over the years.
But STEMI can present in any one of the following odd ways
1. Posterior MI with ST depression in V1 to V3 ( Manytimes mistaken for unstable angina , and reperfusion not considered !)
2.Only with tall T waves (TEMI)
3. Left bundle branch block
4. Present as ventricular tachycardia. Untill VT it is reverted ST elevation will not manifest.
5. When a STEMI presents with complete heart block ST elevation may not manifest.
6.Atypical ECGs and subtle ECG changes are especially common in elderly, diabetic and in patients with LVH.
7. Finally, it is often quoted in text books acute MI occurs with normal ECG in up to 10 % . This is a high estimate .We belive acute MI with normal ECG is very rare presentation < 1% . That too in the very early stages of evolving MI.
As of now only condition No 1 and 3 are approved for thrombolysis or PCI. The unfortunate few who fall in other categories will continue to lose their muscle in the golden hour without any intervention as the guidelines has not addressed these issues.
Dr.S.Venkatesan MD 
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