ST segment depression is the most common ECG sign of ischemia.

  ST segment depression developing during ischemic chest pain disappears in a few minutes

      after resolution of the ischemia.





ECG 1. The ECG above belongs to a patient with stable angina pectoris. The patient complained of effort angina in the last 2
weeks. Coronary angiography was performed and then the patient was referred to coronary artery bypass graft operation
because of 3 vessel disease.
ST segment flattening is one of the first signs of coronary ischemia and generally preceedes ST
segment depression.

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ECG 2. ST segment depression.





ECG 3a. This ECG is from a different patient. The first stage of treadmill exercise test shows no ST segment depression.

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ECG 3b. In the peak exercise,
ST segment depression developes in leads II, III, aVF, V3-V6.

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ECG 3c. Persistence of
ST segment depression in the recovery period (after treadmill has been stopped) suggests severe
coronary ischemia. Lateron, coronary angiography was performed and 3 vessel disease (extensive coronary artery disease)
was diagnosed.

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ECG 4. This 67 years old man complains of chest pain even during resting. He had undergone coronary artery bypass graft
operation. The ECG during the chest pain shows
ST segment depression in leads V2-V6.

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ECG 5. The ECG above belongs to a hypertensive patient with normal coronary arteries. His blood pressure was not under
control for a long time.
ST segment depression is present in lateral leads. The deep S wave in lead C2 and the high R waves
in leads C4 and C5
suggest the presence of left ventricular hypertrophy. In patients with chronic hypertension, observation of
ST depression in lateral leads does not necessarily suggest coronay artery disease.

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ECG 6a. This ECG belongs to a 70 years old patient who complained of chest pain for the last 2 months. Coronary angiography
revealed 99% stenosis in the bifurcation of left main coronary artery, and 70% stenosis in the right coronary artery. The distinct

ST segment depression in leads C3-C6
with mild ST sedpression in inferior leads suggest extensive coronary artery disease.
The presence of
ST segment elevation in lead aVR also raises the suspicion of left main coronary artery disease.

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ECG 6b. This ECG was recorded 6 hours later. Because of the effective medical therapy,
ST depression is now confined only
to C5
.

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ECG 6c. This ECG was recorded 12 hours later, just before the coronary bypass surgery. There is distinct
ST depression in leads
C5 and C6.
Diagnosis of left main coronary artery disease necessitates immediate coronary bypass operation.

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Figure 1a. Coronary angiography of the same patient shows
99% stenosis at the
bifurcation of left main coronary artery
LAD, Cx and
proximal part of left main coronary artery
are normal.



Figure 1b. Coronary angiography of the same patient shows
significant stenosis
of the proximal right coronary artery
.




ECG 7.
ST segment depression is observed in a patient hospitalized for unstable angina pectoris. Coronary angiography
performed on the same day showed significant stenosis of the LAD and Cx coronary arteries. The patient was referred
to coronary artery bypass graft operation.

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ECG 8a. In this patient with coronary artery disease,
ST segment depression and U waves with increased amplitude (higher
than that of the T wave)
is observed during ischemic chest pain.

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ECG 8b. After the disapperance of chest pain, the ECG shows no more ST depression and increased U wave.

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