Typical chest pain with normal ECG F. Mut, C. Bentancourt, M. Beretta Nuclear Medicine Service, Asociacion Española Montevideo, Uruguay
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.
2-D echocardiogram Mild concentric LVH, normal systolic function, LA dilation, normal valves.
Stress ECG Rest Stress Worse ST Recov
Myocardial perfusion study
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.
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).
Vascular territories (17-segment LV model)
Quantitative results Stress LVEF Rest LVEF Stress WMA Rest WMA
The stress perfusion score (SSS) in this case indicates: a) Normal perfusion. b) Mildly abnormal perfusion. c) Moderately abnormal perfusion. d) Severely abnormal perfusion.
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
The LV function parameters indicate: a) Possible myocardial scarring/fibrosis. b) Possible myocardial stunning. c) Possible hibernated myocardium. d) Possible dilated cardiomyopathy.
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.
Contrast ventriculography Normal ventricular function
Coronary angiography left right LAD stenosis (>90%, arrow) Normal LCx Normal RCA
PTCA procedure Pre-procedure Balloon inflation Post-procedure
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).
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.
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