Scenario: Currently under the care of a cardiologist for cardiomyopathy with a low ejection fraction, a 58-year-old man comes to his outpatient cardiology clinic with complaints of recurrent chest discomfort and shortness of breath. Other complaints include a cold “shivering” feeling and nocturnal dyspnea.

Interpretation: Normal sinus rhythm at 85 beats per minute, diffuse ST-segment depression and T-wave inversion, consider acute ischemia, left ventricular hypertrophy (LVH) with strain pattern.

The ST-segment depression and T-wave inversion present in the inferior (II, III, aVF) and the anterolateral (V3 through V6) leads suggest non-ST elevation myocardial infarction (NSTEMI) or unstable angina. The type of ischemia in these conditions typically results from a partially occluded or intermittently occluded coronary artery. Of note, because of the location of the exploring electrode of aVR (right arm), this lead has an endocardial “view”...

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