Depression and elevation of the ST segment in the V4R lead during the stress test of a patient with a proximal lesion of the right coronary artery

: We report a patient with a proximal right coronary artery lesion in whom opposite shifts of ST segment in V4R lead were observed during and after exercise. ST-segment depression was provoked by exercise, while ST-segment elevation appeared in the recovery phase. We speculate that different degrees of myocardial ischemia (non-transmural vs transmural) may explain this apparently paradoxical response.