A 51 year old male with a history of tobacco use and obesity presents to the emergency room with chest pains that began 3 days prior and has been occurring intermittently since then. His blood pressure is 90/60, heart rate 100, respirations 20, and oxygen saturation 93% on room air. His physical examination is significant for pulmonary rales at the bases and an S4 heart sound. His ECG is below. What are the ECG findings?