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

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

Recov

Worse

ST

Stress

Myocardial perfusion study

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).

Vascular territories (17-segment LV model)

Quantitative results

Stress LVEF

Rest LVEF

Stress WMA Rest WMA

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.

Contrast ventriculography

Normal ventricular function

Coronary angiography

LAD stenosis (>90%, arrow)

Normal LCx

Normal RCA

left right

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).

• 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.