Abnormal, Autoquant Adenosine Myocardial Perfusion Heart Imaging. ID: GOLD Date: Age: 46 Sex: M John Doe Phone (310)

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1 Background: Reason: preoperative assessment of CAD, Shortness of Breath Symptom: atypical chest pain Risk factors: hypertension Under influence: a beta blocker Medications: digoxin Height: 66 in. Weight: 180 lbs. Body Mass Index (BMI): 29 History: prior bypass surgery (2/2/1995), Shortness of Breath Adenosine Stress ECG Results: Exercise duration = 09:00 minutes; Rest HR 77; Peak HR 99 (57% of maximum-predicted) Blood Pressure: Rest: 120/60; Stress: 120/60 Reason for termination of exercise: leg fatigue, chest pain Resting ECG: sinus bradycardia, inferoposterior myocardial infarction, anterior myocardial infarction and intraventricular conduction delay < 0.12 sec Stress ECG: -2.3mm additional upsloping ST depression in lead V5 Nuclear Results: Dual isotope gated SPECT [stress sestamibi (Prone and Supine) / rest thallium] Technical quality: good Myocardial Perfusion: overall defects as follows: Vessel Reversible Nonreversible RCA small to medium (inferior/inferoseptal) LAD small (anterior) Total perfusion defect 10% myocardium (3% reversible, 8% fixed) LV enlargement: yes; Visual TID: yes; TID Ratio 1.44 Myocardial Function: LVEF: Rest: 67%; Stress: 57% EDV: Rest: 88ml; Stress: 79ml Resting gated SPECT revealed an ejection fraction of 67% with end-diastolic volume of 88 ml. Post Adenosine resting gated SPECT (performed 120 minutes post injection of sestamibi) revealed a normal left ventricular ejection fraction of 57% with end-diastolic volume of 79 ml. Left ventricular wall motion demonstrated moderate hypokinesis in the septal and apical walls. Conclusion: Perfusion Prob abnormal (Reversible and Clinical Response Ischemic Nonreversible) Function Abnormal rest, worse after stress ECG Response Ischemic (S-T elevation) These test results indicate an intermediate (30-69%) likelihood for the presence of jeopardized myocardium. The type and distribution of the scintigraphic abnormalities are most consistent with the following: in the RCA territory, a small to medium sized prior myocardial infarction involving the inferior and inferoseptal walls; in the LAD territory, a small amount of ischemia in the anterior wall. The severity of the inferior and inferoseptal perfusion defects suggests that the RCA stenosis is critical (>90%). There was left ventricle enlargement at rest. There is also transient ischemic dilation (TID) of the left ventricle which is a marker of severe and extensive coronary artery disease. Thank you for referring this patient to us. Sincerely yours,

2 Level Anterior Inferior 6 5 %Myocardium %Reversible %Fixed Vessel Descriptions Normal/Equivocal 0-4% Normal 0-2% Normal/Equivocal 0-4% RCA (Right Coronary Artery) Mild 5-9% Mild 3-5% Mild 5-9% LAD (Left Anterior Descending) Moderate 10-14% Moderate 6-9% Moderate 10-14% LCX (Left Circumflex) Severe >14% Severe >10% Severe >14% DIAG (Diagonal) Mid-Ventricular Basal Level Vertical Long Axis S R S R S R S R 1. Anterior Anterior Anterior =Normal Inferior Inferior Inferior Date of study Results %Total defects %Reversible %Fixed Stress Prob abnormal 10% 3% 8% Adenosine Normal Reversible Nonreversible 1 =Mildly reduced Equivocal 2 =Moderately Reduced 3 =Severely Reduced 4 =Absent Uptake S = Stress R = Rest Adenosine (34.0 mg) separate aquisition dual isotope gated myocardial perfusion SPECT using Tc-99m sestamibi (20.4 mci) at stress and thallium-201 (4.5 mci) at rest was performed using the rest/stress sequence. Sestamibi SPECT was performed in the supine and prone positions. Findings: overall defects as follows: Vessel Reversible Nonreversible RCA small to medium (inferior/inferoseptal) LAD small (anterior) Myocardial perfusion test result: probably abnormal with both reversible and nonreversible defects.

3 Level Anterior Inferior 6 5 Mid-Ventricular Basal Level Vertical Long Axis S R S R S R S R 1. Anterior Anterior Anterior =Normal =Akinesis 4. Inferior Inferior Inferior LV Ejection Fraction End-diastolic volume TID Ratio 1.44 Rest: 67% Post Stress: 57% Rest: 88 ml Post Stress: 79 ml Normal Moderate / Severe Hypokinesis Akinesis Dyskinesis 1 =Mild Hypokinesis 2 =Moderate Hypokinesis 3 =Severe Hypokinesis 5 =Dyskinesis S = Stress R = Rest Resting gated SPECT revealed an ejection fraction of 67% with end-diastolic volume of 88 ml. Post Adenosine resting gated SPECT (performed 120 minutes post injection of sestamibi) revealed a normal left ventricular ejection fraction of 57% with end-diastolic volume of 79 ml. Left ventricular wall motion demonstrated moderate hypokinesis in the septal and apical walls. Wall motion results: probably abnormal; abnormal rest, worse after stress

4 A total of 34 mg/kg of Adenosine was infused. A standard 12 LEAD ELECTROCARDIOGRAM was recorded in the supine position with continuous ECG monitoring throughout infusion and recovery. Additionally, 12 LEAD ELECTROCARDIOGRAMS were recorded every minute. Adenosine Physiology Heart Rate Rest: 77 Exercise: 99 Blood Pressure Rest: 120/60 Exercise: 150/120 Discomfort Yes Onset of Pain: Stress minute 4 Pain location Arrhythmia Resting Electrocardiogram V5 AVF III Chest None sinus bradycardia, inferoposterior myocardial infarction, anterior myocardial infarction and intraventricular conduction delay < 0.12 sec Maximum Abnormality: -2.3mm additional upsloping Maximum Abnormality: None Maximum Abnormality: None No. of leads with significant S-T depression: 0 Impression Clinical response to Adenosine: Ischemic due to chest discomfort ECG response to Adenosine: Ischemic due to the development of significant ST segment depression Stress ECG interpreted and monitored by John Doe

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