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