Atypical pain and normal exercise test

Transcription

1 Atypical pain and normal exercise test F. Mut, M. Beretta Nuclear Medicine Service, Asociacion Española Montevideo, Uruguay

2 Clinical history 67-year old male with several coronary risk factors. Atypical angina (abdominal discomfort at stress). Normal exercise ECG. Submitted for stress myocardial perfusion study (MPS). Exercise/rest MPS was performed with 99m Tc-sestamibi.

3 Is the perfusion study appropriate? a) No; there is no evidence it would guide the management. b) Yes; there is evidence it could guide the management. c) No; the functional test of choice is stress echo. d) a & c are correct.

4 Is the perfusion study appropriate? a) No; there is no evidence it would guide the management. b) Yes; there is evidence it could guide the management. c) No; the functional test of choice is stress echo. d) a & c are correct. According to Bayes theorem, MPS is indicated for diagnosis in patients with intermediate pre-test probability of coronary artery disease (CAD). Because of age, gender and having atypical symptoms with negative exercise test, our patient is a typical candidate for the test and the result could guide the management (conservative or invasive).

5 Myocardial perfusion study stress rest stress rest stress rest

6 The perfusion result is consistent with: a) Anteroseptal defect - due to LBBB. b) Anterior wall infarction + technical artifact. c) Anterolateral + inferolateral ischemia. d) Inferior + inferolateral ischemia.

7 The perfusion result is consistent with: a) Anteroseptal defect - due to LBBB. b) Anterior wall infarction + technical artifact. c) Anterolateral + inferolateral ischemia. d) Inferior + inferolateral ischemia. There is a perfusion defect at stress (upper row at each panel) involving the inferior and infero-lateral walls, which normalizes almost completely at rest (bottom row at each panel). This is a reversible defect representing ischemia in the territory of the right coronary artery (RCA). Some uptake deficit is still present at rest, probably due to diaphragmatic attenuation which is more common in men (normal finding).

8 Follow-up The patient was submitted to the cath lab. Coronary angiography revealed a critical stenosis of RCA, PTCA was performed successfully and a drug-eluting stent was placed. There were lesions with <50% luminal stenosis in the circumflex artery (Cx) and first diagonal branch. The patient remained asymptomatic at 6 months after the procedure.

9 Teaching points Abdominal pain / discomfort is not infrequent in patients with inferior wall ischemia. Sensitivity of exercise ECG is limited, especially in patients with one-vessel disease. Functional non-invasive stress imaging is indicated in patients with intermediate probability of CAD. MPS has the ability to identify disease in individual arteries, since the perfusion abnormalities usually correlate closely with coronary territories.

10 Bibliography Elhendy A, Sozzi FB, van Domburg RT, et al. Accuracy of exercise stress technetium 99m sestamibi SPECT imaging in the evaluation of the extent and location of coronary artery disease in patients with an earlier myocardial infarction. J Nucl Cardiol 2000; 7: Gibbons RJ. Noninvasive diagnosis and prognosis assessment in chronic coronary artery disease: Stress testing with and without imaging perspective. Circ Cardiovasc Imaging 2008; 1: Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/ SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation 2009;119:e561-e587.