ECG 1a. The ECG above belongs to a 73 years-old hypertensive man with coronary artery disease. He had experienced acute
inferior myocardial infarction previously. Afterwards, he had undergone a coronary artery bypass grafting operation
for 3-vessel disease. Echocardiography showed dilation of left heart chambers and significant left ventricular
systolic dysfunction. Left ventricular ejection fraction was calculated as 19%. He also had symptoms of heart failure.
dEven mild exertion caused yspnea and chest oppression. In addition to the q waves in inferior leads, the above ECG
also shows ST segment depression and asymmetrical T wave negativity suggesting left ventricular strain.

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ECG 1b. Ten minutes after recording of the ECG 8a, the patient complained of chest oppression and a second ECG was recorded.
The ST segment elevation in leads C2 and C3, and the ST segment depression in leads C5 and C6 are accentuated in this
second ECG. Observation of dynamic ECG changes even in a patient with left ventricular strain pattern should raise the
suspicion of myocardial ischemia. A sublingual nitrate tablet was administered immediately after recording of the above ECG.

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ECG 1c. A third ECG was recorded 10 minutes after sublingual nitrate administration.
The new-onset ST segment elevations and depressions in the precordial leads have gone in this ECG.
Left ventricular strain pattern still exists.
The patient underwent coronary angiography after this ECG and a coronary stent was implanted.

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ECG 1d. His ECG one year-later shows left ventricular strain pattern. He is still asymptomatic.

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ECG 2. The ECG above belongs to a 73 years-old man with chronic hypertension. He complained of typical effort angina.
The above ECG was recorded at rest (during the pain-free period).
His ECG shows increased voltage suggestive of left ventricular hypertrophy, strain pattern and short PR interval.
Coronary angiography was performed on the same day and 95% stenosis was detected in the LAD coronary artery.
His ECG does not show typical ischemic changes. Patients with stable angina may have normal ECGs during the angina-free
period. If there are no dynamic ECG changes (suggesting unstable angina pectoris) in such a patient, it will be impossible to
diagnose coronary artery disease without performing further diagnostic tests.

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ECG 3. The ECG above belongs to a 65 years-old woman with chronic hypertension. She had undergone coronary artery
bypass graft operation 3 years ago. The ECG is remarkable for increased voltage criteria for left ventricular hypertrophy.
However, the widespread T wave negativity in the chest leads cannot be explained by strain pattern alone. Left ventricular
strain pattern does not involve whole chest leads. This patient was complaining of typical retrosternal chest pain.
She had undergone coronary angiography on the same day with this ECG and a stent was implanted to her Circumflex
coronary artery.

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ECG 4a. The ECG above is from a 60 years-old hypertensive man who had undergone coronary artery bypass graft operation
(only LIMA to LAD) 7 years ago. When he was admitted to the Emergency Room with the complaint of chest pain,
left ventricular strain pattern was observed in his ECG.

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ECG 4b. Because of the persisting attacks of chest pain, another ECG was recorded 2 days later (above).
This time, the ST segment depression in leads V3 to V6 were deepened. Urgent coronary angiography was performed, which
showed a normal RCA and a competent LIMA bypass graft. However, significant stenoses were observed at the origins of the
Circumflex (Cx) and intermediary arteries: lateral ischemia.
Dynamic ECG changes are not expected in left ventricular strain pattern.

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Figure 1. His left coronary arteriogram (spider view) showed significant stenoses at the origins of the
intermediary and Cx coronary
arteries. Even a stump was not detected at the expected origin of the
LAD artery,
Observation of dynamic ECG changes in a patient with previous LV strain pattern should suggest the presence of
coexisting myocardial ischemia




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