Acute MI, the pt spilled troponin to 7.52.

So, how do you diagnose this acute MI in the face of a pre-existing LBBB?

One thing would be to say that the morphology is changed from prior. But more importantly, and more concerning, is that this patient meets one of the Sgarbossa criteria, specifically criteria #2: ST-segment depression = 1 mm in V1, V2, or V3. In fact, the pt meets that criteria in V1, V2, AND V3 (and the Sgarbossa criteria only require that the pt meet the criteria in just one of V1, V2, OR V3. Moreover, the EKG from one-month prior did not meet these criteria, so these changes are new.