Unstable angina pectoris

  Unstable angina pectoris is a clinical diagnosis.

  There is
NO diagnostic / pathognomonic ECG finding.

  Various ECG signs of ischemia may be observed during unstable angina pectoris.

  ECG findings may show
dynamic changes.

      Yesterday's ECG abnormality may not be observed today and

      a different ECG abnormality may arise next day.

  Clinically unstable angina is between stable angina pectoris and acute myocardial infarction.

  Not all patients with acute myocardial infarction experience the phases of stable and unstable angina

      pectoris serially.

  Some patients with stable angina pectoris may have acute myocardial infarction before experiencing

      unstable angina pectoris.




ECG findings that may be observed during unstable angina pectoris

  ST segment depression

  ST segment elevation

  T wave negativity

  Prominent T waves (increased amplitude of T waves)

  Negative U waves

  Atrioventricular (AV) blocks

  Arrhythmias

  QT interval prolongation




Caution

  Slightly horizontal or downsloping ST segment depression may be observed as a normal variant,

      especially in women.

  Patients with
left ventricular hypertrophy may have secondary ST segment depression / elevation

      and / or T wave negativity (Strain pattern).

  In patients with cardiac pacemakers, pacemaker-induced beats may mask the typical signs of ischemia.





ECG 1. The ECG above belongs to a 72 years-old woman with unstable angina pectoris. It was recorded the Emergency Room
just before coronary angiography. She was complaining of attacks of widespread retrosternal chest pain which were lasting
up to 30 minutes. Her chest pain was not related to effort. The ECG shows
VPC and ST segment depression .

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Figure 1a. Urgent coronary angiography showed
significant stenosis in the right coronary artery (RCA).




Figure 1b. Above is her coronary angiogram after successful stenting of the RCA.





ECG 2. The ECG above belongs to a 78 years-old man. It shows prominent T waves in the right precordials (V1-V3), and ST
segment depression and negative T waves in inferior leads. The leads V5 and V6 show more prominent ST depression.
Clinically she was diagnosed as unstable angina pectoris. Her coronary angiography showed 80% stenosis of the left
anterior descending (LAD) coronary artery. The rhythm is atrial fibrillation.

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ECG 3. The ECG above belongs to a 68 years-old man who had previously undergone coronary artery bypass graft surgery.
He was complaining of typical widespread chest pain unrelated to effort. He is under beta blocker therapy. His ECG shows

ST segment flattening
in anterior leads and prominent T waves in leads V2 and V3. Lead III shows negative T waves.

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ECG 4. The ECG above belongs to a 41 years-old man who is complaining of typical widespread chest pain unrelated to effort.
Coronary arteriography was performed although he had no ECG signs of ischemia. The Left Anterior Descending (LAD)
coronary artery was totally occluded proximally and was retrogradely receiving blood from the Right Coronary Artery
(RCA). He had not experienced acute myoardial infarction due to very slow occlusion of the LAD. This case shows that
a normal ECG does not rule out the presence of coronary artery disease . The patient's complaints should not be ignored.

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ECG 5a. The ECG above belongs to a 66 years-old man who is complaining of epigastric pain. The ECG does not show typical
signs of myocardial ischemia.

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ECG 5b. His ECG, 4 days later, showed widespread ST segment depression. After this ECG, he was transferred to our hospital
for urgent coronary angiography.

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ECG 5c. The ECG above was recorded just before coronary angiography. Widespread ST depression has disappeared.

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Figure 5. Coronary angiography showed signicant stenoses of
the Circumflex and
the Left Anterior Descending (LAD)
coronary arteries.





ECG 6. The ECG above belongs to a 60 years-old woman with normal coronary arteries.
Precordial leads show slight ST segment depression with negative T waves.

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ECG 7. The ECG above belongs to a 64 years-old woman with uncontrolled hypertension and left ventricular hypertrophy.
She has normal coronary arteries. ST segment depression is seen in leads V4 to V6.

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