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A 43 year old woman with a 40 year history of exertional chest pain

BMJ 2012; 344 doi: (Published 02 February 2012) Cite this as: BMJ 2012;344:e628
  1. P D Morris, specialist registrar in cardiology1,
  2. K J Trevest, specialty trainee1,
  3. A Y Butt, consultant cardiologist2,
  4. E D Grech, consultant cardiologist1
  1. 1Northern General Hospital, Chesterman Unit, Sheffield S5 7AU, UK
  2. 2Chesterfield Royal Hospital, Chesterfield, UK
  1. Correspondence to: P Morris paulmorris{at}

A 43 year old Asian woman was referred to the cardiology outpatient clinic with recurrent episodes of chest pain, which she had experienced since early childhood. She described the chest pain as a central tightness that occurred when she exercised. She had recently developed paroxysms of fast regular palpitations, which had prompted her referral. Her only known coronary risk factor was a family history of premature coronary disease. Physical examination was unremarkable and her blood pressure was 110/56 mm Hg. Routine haematology and biochemistry tests, including her thyroid stimulating hormone concentration, were all within normal limits. A 12 lead electrocardiogram (ECG) showed normal sinus rhythm. A 24 hour Holter ECG showed sinus rhythm with occasional supraventricular ectopic beats and no suggestions of any ST segment change (no diary entries). Chest radiography, echocardiography, and pulmonary function tests were unremarkable. She went on to have a Bruce protocol exercise tolerance test. Her ECG at peak exercise (eight minutes) is shown (fig 1).

Fig 1 Exercise tolerance electrocardiogram


  • 1 What does the exercise tolerance ECG show?

  • 2 What are the possible underlying causes of the ECG changes?

  • 3 Computed tomography coronary angiography showed an anomalous right coronary artery emanating from the left coronary sinus. Why is this a problem and how does it explain the ischaemia?

  • 4 What further investigations should be considered?

  • 5 How might this condition be managed?


1 What does the exercise tolerance ECG show?

Short answer

Down-sloping ST segment depression in the lateral leads (V4-V6), which is suggestive of myocardial ischaemia (fig 2).

Fig 2 Exercise tolerance electrocardiogram showing ST segment depression in leads V4, V5, and V6 (arrows)

Long answer

Down-sloping and planar (horizontal) ST segment depression are more specific for underlying ischaemia than up-sloping ST depression, which can be a normal phenomenon during exercise. The depth of ST depression (1.5 mm in this case) is …

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