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Asymptomatic patient with
positive stress test
F. Mut, M. Beretta, C. Bentancourt
Nuclear Medicine Service, Asociacion Española
Montevideo, Uruguay
• Man 81 y.o.
• Dyslipemia, stress, overweight, family history.
• Asymptomatic with positive exercise test.
• Aortic stenosis.
• EKG: synus rythm 75 bpm, mild repolarization changes.
• The patient underwent a dipyridamole/rest myocardial
perfusion gated SPECT study with 99mTc-MIBI.
Clinical history
Myocardial perfusion study
Quantitation of perfusion and function
a) One-vessel disease.
b) Two-vessel disease.
c) Three-vessel disease.
d) Diffuse subendocardial ischemia.
The gated SPECT results indicate:
a) One-vessel disease.
b) Two-vessel disease.
c) Three-vessel disease.
d) Diffuse subendocardial ischemia.
The gated SPECT results indicate:
• There are multiple, reversible perfusion defects involving all
three major vascular territories.
• There is a drop in post-stress LVEF (60% to 47%) and
transient dilation of the left ventricle.
How would you manage the patient?
a) Perform invasive coronary angiography.
b) Perform CT angiography.
c) Perform PET viability study.
d) Do nothing but medical treatment.
How would you manage the patient?
a) Perform invasive coronary angiography.
b) Perform CT angiography.
c) Perform PET viability study.
d) Do nothing but medical treatment.
• The patient has a high risk gated SPECT result, so he might
benefit from myocardial revascularization.
• CT angiography or PET would not add to patient
management in this scenario.
• Medical treatment alone is associated with higher cardiac
event rate in these patients.
Coronary angiography Left coronary artery – anterior view Left coronary artery – LAO view
Right coronary artery
Coronary angiography Left coronary artery – anterior view Left coronary artery – LAO view
Right coronary artery
• Results showed multivessel disease.
• The patient underwent CABG.
• Myocardial perfusion imaging is useful for identifying
multivessel disease, since most patients have perfusion
abnormalities indicative of ischemia.
• In few cases, balanced ischemia can produce “normal”
perfusion images but frequently showing myocardial
stunning with transient LV dilation and lower post-stress
LVEF.
• High risk studies indicate the need for aggressive management.
Teaching points
• Travin MI, Katz MS, Moulton AW, Miele NJ, Sharaf BL, Johnson LL.
Accuracy of dipyridamole SPECT imaging in identifying individual
coronary stenoses and multivessel disease in women versus men. J Nucl
Cardiol 2000;7:213-20.
• Hida S, Chikamori T, Tanaka H, Usui Y, Igarashi Y, Nagao T, Yamashina A.
Diagnostic value of left ventricular function after stress and at rest in the
detection of multivessel coronary artery disease as assessed by
electrocardiogram-gated SPECT. J Nucl Cardiol 2007;14:68-74.
• Beller GA, Ragosta M. Decision making in multivessel coronary disease:
the need for physiological lesion assessment. JACC Cardiovasc Interv
2010;3:315-7.
• Siqueira ME, Segundo Neto EM, Kelendjian JF, Smanio PE. Diagnostic
value of myocardial radionuclide imaging in patients with multivessel
coronary disease. Arq Bras Cardiol 2011;97:194-8.
Bibliography
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