A 60-year-old woman who has been treated for hypertension due to renal artery stenosis, is presenting with recent onset of angina on exertion:

• Sinus rhythm
• Left atrial enlargement
• Left ventricular hypertrophy
• T wave abnormality, consider lateral ischemia

In the typical “strain pattern” of left ventricular hypertrophy there is downsloping ST depression followed by an inverted T in the left leads. In this case the flat ST preceding the negative T wave suggests the possibility of ischemia, particularly in view of the recent onset of angina. Similar changes, however, may be seen in patient with left ventricular hypertrophy, in the absence of coronary artery disease. The significance of the T waves abnormalities should always be assesses on clinical ground.
This patient underwent coronary angiography that proved the presence of coronary artery disease.