What is diagnostic of fresh myocardial infraction in ECG

diagnostic changes of acute or evolving ischemia are often masked by the presence of left bundle branch block, electronic ventricular pacemaker patterns, and Wolff- Parkinson-White preexcitation. However, clinicians continue to over- diagnose ischemia or infarction based on the presence of ST-segment elevations or depressions; T-wave inversions; tall, positive T waves; or Q waves not related to ischemic hea disease (pseudoinfarct pat- terns). Ref Harrison 20th edition pg 1435