The standard 12‑lead electrocardiogram (ECG) has become a mainstay diagnostic tool in patients suspected to have myocardial ischemia. The identification of hallmark electrocardiographic abnormalities, such as ST-segment deviation or serial T wave changes, not only helps identify the presence of myocardial ischemia but also may help localize myocardial territories with an ongoing injury. Widespread ST-segment depression is commonly attributed to diffuse subendocardial ischemia precipitated by severe multivessel or left main coronary artery disease. However, among patients with prior coronary revascularization, clear electrocardiographic-angiographic relationships responsible for widespread ST-segment depressions have not been well defined. We report a case in which diffuse ST-segment depression emerged from a patient with prior coronary artery bypass grafting. In this report, we examine the patient's presenting ECG pattern as to (1) establish causal inferences which align with the distribution of myocardial ischemia supported by angiography and (2) provide an accompanying analysis of the relevant scientific literature.
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