Typical chest pain with normal ECG

Transcription

1 Typical chest pain with normal ECG F. Mut, C. Bentancourt, M. Beretta Nuclear Medicine Service, Asociacion Española Montevideo, Uruguay

2 Clinical history Male 41 y.o. Overweight, hypertension, high cholesterol, stress. Typical chest pain. Echocardiogram: mild LVH, normal LV function. Exercise test: chest pain witn no ECG changes Myocardial perfusion study (MPS) with exerecise.

3 2-D echocardiogram Mild concentric LVH, normal systolic function, LA dilation, normal valves.

4 Stress ECG Rest Stress Worse ST Recov

5 Myocardial perfusion study

6 The study demonstrates: a) Ischemia in the RCA territory. b) Ischemia in the LCx territory. c) Ischemia in the LAD territory. d) Ischemia in the RCA + LAD territories.

7 The study demonstrates: a) Ischemia in the RCA territory. b) Ischemia in the LCx territory. c) Ischemia in the LAD territory. d) Ischemia in the RCA + LAD territories. There is a severe, extense, reversible anteroseptoapical perfusion defect which is characteristic of ischemia affecting the LAD territory. From the study viewpoint, this is consistent with single-vessel disease (segments 1,2,7,8,13,14,17).

8 Vascular territories (17-segment LV model)

9 Quantitative results Stress LVEF Rest LVEF Stress WMA Rest WMA

10 The stress perfusion score (SSS) in this case indicates: a) Normal perfusion. b) Mildly abnormal perfusion. c) Moderately abnormal perfusion. d) Severely abnormal perfusion.

11 The stress perfusion score (SSS) in this case indicates: a) Normal perfusion. b) Mildly abnormal perfusion. c) Moderately abnormal perfusion. d) Severely abnormal perfusion (18). SSS <4 = Normal 4-8 = Mildly abnormal 9-13 = Moderately abnormal >13 = Severely abnormal

12 The LV function parameters indicate: a) Possible myocardial scarring/fibrosis. b) Possible myocardial stunning. c) Possible hibernated myocardium. d) Possible dilated cardiomyopathy.

13 The LV function parameters indicate: a) Possible myocardial scarring/fibrosis. b) Possible myocardial stunning. c) Possible hibernated myocardium. d) Possible dilated cardiomyopathy. There is a drop in post-stress LVEF (67% rest vs. 52% poststress) and development of regional hypokinesis in wall motion analysis (WMA). Both are typical findings of post-ischemic regional ventricular dysfunction or myocardial stunning.

14 Contrast ventriculography Normal ventricular function

15 Coronary angiography left right LAD stenosis (>90%, arrow) Normal LCx Normal RCA

16 PTCA procedure Pre-procedure Balloon inflation Post-procedure

17 Follow-up 4 months after successful PTCA, the patient is asymptomatic and controlling risk factors with medication and life-style modifications. Exercise test with no symptoms and normal ECG (below).

18 Teaching points In patients with no known coronary artery disease and at overall low-tointermediate risk, myocardial perfusion SPECT adds prognostic information and risk-stratifies patients beyond clinical and exercise data. Semiquantitative information obtained by gated SPECT provides important measurements of disease extent and severity. Perfusion scores are useful tools in clinical decision making and have been shown to have independent risk-stratification value. Post-ischemic stunning, as assessed by gated SPECT, is a marker for poor prognosis, particularly for ischemic cardiac events. Patients with high risk results should be managed aggressively - with revascularization procedures if possible.

19 Bibliography Johnson LL, Verdesca SA, Aude WY, et al. Postischemic stunning can affect left ventricular ejection fraction and regional wall motion on post-stress gated sestamibi tomograms. J Am Coll Cardiol 1997; 30: Hachamovitch R, Berman DS, Shaw LJ, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 1998; 97: Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002; 105: Usui Y, Chikamori T, Nakajima K, et al. J-ACCESS Investigators. Prognostic value of post-ischemic stunning as assessed by gated myocardial perfusion singlephoton emission computed tomography: a subanalysis of the J-ACCESS study. Circ J 2010; 74: