Typical chest pain with normal ECG - Human … chest pain with normal ECG F. Mut, C. Bentancourt, M. Beretta Nuclear Medicine Service, Asociacion Española Montevideo, Uruguay Clinical
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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.
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.
The study demonstrates:
• 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).
a) Normal perfusion.
b) Mildly abnormal perfusion.
c) Moderately abnormal perfusion.
d) Severely abnormal perfusion.
The stress perfusion score (SSS)
in this case indicates:
<4 = Normal
4-8 = Mildly abnormal
9-13 = Moderately abnormal
>13 = Severely abnormal
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
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.
The LV function parameters indicate:
• There is a drop in post-stress LVEF (67% rest vs. 52% post-
stress) and development of regional hypokinesis in wall
motion analysis (WMA).
• Both are typical findings of post-ischemic regional ventricular
dysfunction or myocardial stunning.
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).
• In patients with no known coronary artery disease and at overall low-to-
intermediate 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.
Teaching points
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; 30:1641-8.
• 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; 97:535-43.
• 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; 105:539-42.
• Usui Y, Chikamori T, Nakajima K, et al. J-ACCESS Investigators. Prognostic value
of post-ischemic stunning as assessed by gated myocardial perfusion single-
photon emission computed tomography: a subanalysis of the J-ACCESS study.
Circ J 2010; 74:1591-9.
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