ECG of the Month: Melena and Chest Pain

The patient is a 77-year-old man with a history of type 2 diabetes mellitus, coronary artery disease s/p 3v CABG, and bioprosthetic AVR 20 years ago, paroxysmal atrial fibrillation on warfarin, and angioectasia. He is seen in emergency department because of abdominal pain, melena and chest heaviness for 3 days. His INR was found to be 13, hemoglobin 8.7 and troponin 1.10. An ECG was performed (Figure 1):

Figure 1

Figure 1

The ECG shows which of the following:

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