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





ECG 5. The compact ECG above belongs to a 50 years-old woman who had undergone coronary artery bypass graft operation
previously. She has chronic systemic arterial hypertension for more than 20 years.
The compact ECG above shows more than isolated left ventricular strain pattern.
The
T wave negativity in leads V3 to V4 suggests the presence of coronary artery disease.
Left ventricular strain pattern due to left ventricular hypertrophy does not involve leads V3 and V4.
There is also intraventricular conduction defect with a QRS width of 116 milliseconds.





ECG 6. The compact ECG above belongs to a 75 years-old hypertensive man with the complaint of retrosternal chest pain.
He was diagnosed as Unstable Angina Pectoris.
The ECG machine's computer commented "left ventricular hypertrophy with repolarization abnormality".
The diagnosis is true but incomplete.
Left ventricular strain pattern due to left ventricular hypertrophy does not involve leads V1 to V4.
After recording of the above ECG, he underwent coronary angiography which showed 3-vessel disease (extensive coronary
artery disease) and coronary artery bypass grafting operation was advised.






ECG 7. The compact ECG above belongs to a 85 years-old hypertensive woman with extensive coronary artery disease and
mild to moderate aortic valve insufficiency.
The patient is very lean with a body weight of 45 kgs only.
The rhythm is atrial fibrillation and P waves are absent.
The precordial QRS voltage is increased due to both left ventricular hypertrophy and lean body habitus.
However, strain pattern is not the only abnormality in the above ECG.
The negative T waves in leads V3 and V4 are due to coronary artery disease.
Isolated left ventricular strain pattern does not involve leads V3 and V4.
ST segment depresion in leads II and aVF also suggest coronary artery disease.
She is not under Digoxin therapy.






ECG 8. The compact ECG above belongs to a 58 years-old hypertensive man with chronic systemic arterial hypertension.
He also has hemodynamically significant aortic valve stenosis and coronary artery disease.
ECHOcardiography showed left ventricular hypertrophy.
Negative T waves and ST segment depression are not only confined to V5 and V6 but also seen in lead V4.
The ECG computer underdiagnosed this patient by not reporting the possibility of coronary artery disease.






ECG 9. The compact ECG above belongs to a 71 years-old hypertensive man with chronic systemic arterial hypertension.
and aortic valve stenosis. ECHOcardiography showed asymmetrical septal hypertrophy in this man.
Leads V2 to V6 show T wave negativity while leads V4 to V6 show ST segment depression.
These findings cannot be explained by left ventricular strain alone.
A coronary stent had been previously implanted to the LAD coronary artery of this man.
After recording the above ECG, coronary angiography was performed and a stent was implanted to the first Diagonal branch
of his LAD artery.
PR interval is prolonged (228 ms) despite the absence of beta blocker, Diltiazem or Verapamil use.
Calcific aortic valve stenosis predisposes to the development of first degree AV block.






ECG 10. Above ECG is from a 76 years-old hypertensive woman who had undergone coronary artery bypass surgery.
ECHOcardiography showed normal left ventricular systolic function (wall motion) and normal cardiac valves.
Asymmetrical negative T waves and ST segment depression in lateral leads are compatible with strain pattern.
However, horizontal ST segment depression in leads I, II and aVF suggest myocardial ischemia.
Coronary angiography showed significant stenoses in Diagonal and well-developed Obtus marginale branches.

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ECG 11. The compact ECG above is from a 56 years-old untreated hypertensive man.
Asymmetrical negative T waves and ST segment depression in V5 and V6 are compatible with left ventricular (LV)
strain pattern. However, q waves with negative T waves in inferior leads (II, III and aVF) suggest coronary artery disease.
Indeed, ECHOcardiography showed severe hypokinesia of the inferior LV wall.
His LV was not dilated and LV ejection fraction was measured as %42 (depressed LV systolic function).