IAEA Resource Listings
2013
History of MI and PTCA/stent and recurrent chest pain
Case presentation:
Female.
61 y.o.
168cm Ht.
86kg Weight.
CABG in1993 for TVD.
Acute MI 8/12 before scan, PTCA/Stent.
CAD risk: family history, hyperlipidemia, diabetes mellitus, hypertension.
Study: Dipyridamole/ Thallium for recurrent chest pain.
Teaching points:
In patients with previous CABG or PTCA, recurrent chest pain is an indication for myocardial perfusion imaging (MPI).
The test can be useful to detect presence and severity of ischemia, as well as to identify the culprit vessel.
Often, extension and severity of perfusion defects largely exceed abnormal ECG findings.
2013
Symptomatic with hypertension history - suspected CAD
Case presentation:
Male.
67 y.o.
Exertional shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea.
Hypertension.
Type II DM.
Hyperlipidemia.
Referred for further evaluation.
Able to exercise, TMX-MPI decided upon.
2013
Atypical chest discomforts on exertion (stairs) and rest
Case presentation:
Female.
70 y.o.
Hypertension, Hyperlipidemia, NIDDM.
Presents with atypical chest discomforts on exertion (stairs) and rest.
TMX performed in Yangon.
2013
Viability Assessment-Cardiogenic shock at the Emergency Department
Case presentation:
Patient 1
Male.
45 y.o.
Hyperlipidemia, Hypertension, Diabetes Mellitus.
Presented with cardiogenic shock at the Emergency Department, treated with IABP and inotropic support initially.
Intervention performed 3/7 after admission.
Various cardiac imagings performed about 2 months later for progressive dyspnoea, NYHA IV.
Patient 2
Female.
56 y.o.
Presented at ER with a 4 day history of worsening dyspnoea at rest.
No chest discomfort.
Diabetes Mellitus.
Hypertension.
Hyperlipidemia.
2013
Acute cardiac event
Case presentation:
Male.
51 y.o.
185cm Ht.
CAD risk (Hyperlipidemia).
Smoker.
3/7 after acute cardiac event.
Study: adenosine/ sestamibi.
Teaching points:
Myocardial perfusion imaging (MPI) is useful in acute coronary syndromes to:Confirm / rule out MI.Evaluate extension of ischemia / scar. Identify the culprit vessel.
2013
Chest pain precipitated by physical exertion
Case presentation: - Male. -38 y.o. - Exertiona chest pain -No CAD risk factors -Study: Exercise/ Tetrofosmin. - 75kg weight. - Ht 180 cm. Teaching points: -This is an intermediate probability pre-test case (young male with no risk factors and chest pain). -Myocardial perfusion imaging (MPI) is indicated since whatever the result is, it will have impact on patient management (Bayes’ theorem). - Sensitivity of MPI is much higher than exercise ECG for ischemia detection. -This result is high-risk for cardiac events, so the patient should be considered for urgent invasive management (angiography + PTCA).
2013
Mild TVD on CTA and MPI
Case presentation:
Male
48 y.o.
Health screeening CTA, no symptoms.
Hyperlipidemia.
Physical exam.
Normal CVS findings.
BP 145/78.
78kg weight.
Ht 172 cm.
2013
Chest discomfort - suspected CAD
Case presentation:
Female.
49 y.o.
Exertional shortness of breath, dull pressing chest discomforts for 6 months.
103kg weight. Obese.
Hypertension.
Type II DM.
Hyperlipidemia.
Conclusions:
Attenuation artifacts are the achilles heel of MPI. In most cases, there is a mild to moderate fixed perfusion defect in the anterior and antero-septal or antero-lateral walls depending on the position the breasts. In this case however, there was what appeared to be a reversible defect seen. This could be because the breast position may have changed between the 2 scans, or perhaps because a different position of camera head has been employed.
Measures to reduce this type of artifact would be possibly breast strapping or using attenuation correction measures.
2013
Known CAD, chest pain and LBBB
Case presentation:
Male.
65 y.o.
Previous MPI 1 year ago, told “no major problems”.
Hypertension.
Hyperlipidemia.
New onset chest discomfort.
Pharmacologic MPI
2013
Viral Myocarditis
Case presentation:
Female.
66 y.o.
Hospital worker.
Felt unwell for 3/52 before admission, with flu like symptoms.
Hypertension.
Hyperlipidemia.
New onset of dull chest pain and breathlessness at rest (NYHA II-III).
2013
Pre-operatory assessment for knee surger
Case presentation:
Female
65 y.o.
Brassier size 34b
History of chronic obstructive pulmonary disease.
CAD risk: hypertension.
Study: Dobutamine/ Thallium.
58kg weight.
Ht 161 cm
2013
Takotsubo
Case presentation:
Female.?
73 y.o.
Palpitations & Giddiness for 2 months .
Hyperlipidemia (LDL 2.49) on statin.
Hypertension (160/100) on diuretic ?Lumbar Spondylosis, Gastritis, Fatty Liver, Cataracts.
Non specific symptoms.
Teaching points:
Reversible form of LV dysfunction, characterized by apical akinesis, usually precipitated by extreme emotional stress.
Possibly mediated by sympathetic hyperactivity, resulting in a neurogenic stunned myocardium (microvascular dysfunction).
“Tako-tsubo” derived from a japanese pot for trapping octopus.
Good prognosis.
2013
Post CABG Ischemia
Case presentation:
Female.
66 y.o.
Presented with typical chest pains (NSTEMI), NYHA II.
Hyperlipidemia.
Hypertension.
Type II Diabetes.
Medically stabilized & sent for coronary revascularization on 2nd day of admission.
2013
Perfusion agent injected during chest pain and after PTCA
Case presentation:
Male.
60 y.o.
Poorly controlled type II diabetes mellitus (DM).
Presents at the Emergency Department (ED) with chest pain at rest with radiation to right shoulder, lasting for about 45 min but relapsing several times during the last 24 hours, with no other symptoms.
At admission, BP is 140/90 mmHg, regular cardiac rhythm of 70 bpm, physical examination otherwise unremarkable.
Troponin I and CPK MB within normal limits.
Teaching points:
In the absence of previous MI, or in patients with no previous history of CAD, rest MPS can depict ACS with high accuracy.
Rest MPS are class IA indication for ED imaging in patiens with chest pain and nondiagnostic ECG, serum markers and enzymes, according to the ACC/AHA/ASNC Guidelines.
The use of MPS to guide admission can result in unnecessary hospitalizations and in reduction of inappropriate discharges from the ED; this is also true for patients with DM (ERASE Chest Pain Trial).
2013
Adolescent with effort dyspnea
Case presentation:
Female.
16 y.o.
Family history of sudden death (father).
Pactices sports regularly.
Presents with effort dyspnea.
At physical examination, systolic murmur 3/6.
Otherwise unremarkable.
Teaching points:
HCM is the most frequent hereditary cardiovascular disease (0.2% global incidence).
Autosomic dominance caused by mutations in at least 13 genes which codify the cardiac sarcomer proteins, being the most frequent.
LVH associated with HCM may cause false positive results in ECG (ST depression), symptoms (chest pain) and MPS results (TID, drop in post-stress LVEF).
2012
TID with normal myocardial perfusion
Case presentation:
Male.
51 y.o.
Hypertension and diabetes.
Atypical sympotons (right are discomfort st stress).
Echocardiography revealed LVH.
Submitted for stress myocardial perfusion study (MPS).
Teaching points:
Although TID is usually higher in patients with LAD ischemia or multivessel disease (MVD), it can also be found in patients with LVH or diabetes (like in this case).
However, TID in the absence of evident perfusion abnormalities should always raise the question of balanced myocardial ischemia in the first place, which is more common in MVD.
Exercise/rest MPS was performed with 99m-Tc-sestamibi.
2012
Dyspnea in adult patient with corrected Tetralogy of Fallot
Case presentation:
Male.
51 y.o.
Tetralogy of Fallot (TF) - acyanotic form.
Operated 16 years before
Dyspnea.
EKG: LV, RV hypertrophy, repolarization changes.
Echo: LVH, RVH with preserved systolic function of both ventricles, mild pulmonary valve stenosis.
MPS was indicated to rule out associated CAD.
Teaching points:
TF is the most common cyanotic heart defect seen in children beyond infancy, the most common cyanotic congenital lesion likely to result in survival to adulthood, and currently the most common complex lesion to be encountered in adults after repair.
TID can be the consequence of segmental or diffuse ischemia. Lack of proportionate microvascular growth in myocardial hypertrophy leaves the myocardium vulnerable to ischemia even in the absence of atherosclerotic plaques (diffuse vs. segmental ischemia).
In addition to RV hypertrophy, LVH can develop due to LV overload in TF.
Patients with acyanotic TF (or pink TF) may be asymptomatic or may show signs of heart failure from a large left-to-right shunt.
Occasionally, an individual reaches adulthood without any surgical repair, although this is not common.
Echocardiography is the modality of choice for the postoperative follow-up evaluation of patients with palliated or repaired TF.
Residual abnormalities range from nearly normal heart to substantial RV dysfunction and residual RV outflow tract obstruction.
MPS can be indicated in adult cases in which symptoms may resemble those from coronary artery disease.
2012
MPI and Calcium Score in asymptomatic patient
Case presentation: -Male. -63 y.o. - Knee osteoarthritis limiting exercise capacity. - Hypertension (BP 145/90 mmHg under medication). - Family history of CAD (father had sudden death at 53). - Total Cholesterol = 223; HDL = 45; LDL = 128, Gluc = 0.97. Teaching points - CAC provides independent incremental information in addition to traditional risk factors in the prediction of allcause mortality. - The principal difference between MPS and Ca scoring is that the former is an excellent tool for assessing shortterm risk, guiding decisions on revascularization.? - In contrast, atherosclerosis imaging methods like CAC provide greater long-term risk assessment, and are more useful in defining the need for aggressive medical prevention.
2012
MPI + CTA in patient with atypical chest pain
Case presentation:
Female.
59 y.o.
Atypical chest pain for the past 6 months.
Total Cholesterol = 190; HDL = 40; LDL = 88 (on statins).
Glucose: 0.93, HbA1C = 6.7 % (on insulin + metformin).
Teaching points:
MPS investigates the pathophysiological consequences of luminal obstructive CAD, while CTA indicates the presence, extent and location of coronary atherosclerosis.
For pratical purposes, CTA excludes CAD (high NPV).
A negative CTA implies no need of MPS on follow-up.
A positive CTA (if performed initially) implies the need for a MPS for short-term prognosis and eventual revascularization, because of low PPV.
Combined anatomical and functional assessment may allow improved risk stratification.
2012
Symptoms of heart failure with normal ECG
Case presentation:
Female.
63 y.o.
Overweight, hypertension, dyslipemia, type II diabetes.
Mild/moderate renal insufficiency.
2 acute episodes of pulmonary edema 8-3 months before.
Presents with chest pain and weakness after mild exercise.
The rest ECG was totally normal. -Medication: ARBS, diuretics, metformin, statins.
Teaching points:
Myocardial viability assessment is indicated in patients with chronic LV dysfunction.
In patients with LV dysfunction and myocardial viability, the mortality is significantly lower in those treated with revascularization than those treated medically.
The extent of perfusion–metabolism mismatch is proportional to mortality rate in medically treated patients with chronic ischemic LV dysfunction.