IAEA Resource Listings
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
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
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
Asymptomatic patient with positive stress test
Case presentation:
Male.
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 Teaching points
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.
2012
Atypical pain and normal exercise test
Case presentation:
Male.
67 y.o.
Atypical angina (abdominal discomfort at stress).
Normal exercise ECG.
Submitted for stress myocardial perfusion study (MPS).
Exercise/rest MPS was performed with 99mTc-sestamibi.
Teaching points:
Abdominal pain / discomfort is not infrequent in patients with inferior wall ischemia.
Sensitivity of exercise ECG is limited, especially in patients with one-vessel disease.
Functional non-invasive stress imaging is indicated in patients with intermediate probability of CAD.
MPS has the ability to identify disease in individual arteries, since the perfusion abnormalities usually correlate closely with coronary territories.
2012
Dyspnea and chest pain at exertion
Case presentation:
Male.
63 y.o.
Hypertension.
Dyspnea and chest pain when exercising, progressive.
Normal rest ECG. - Stress echo: poor acoustic window, technically suboptimal.
Myocardial perfusion study with exercise (99mTc-sestamibi). -Stress test: Chest pain, mild ECG changes, drop in SBP.
Teaching points:
Post-stress increased RV uptake has prognostic implications and can reflect RV pressure overload due to postischemic LV dysfunction.
Post-stress increased RV activity can be also an indicator of stress-induced RV:LV perfusion imbalance associated with severe CAD (e.g., high-grade left main stenosis with less severe proximal right CAD stenosis).
The amount of inducible ischemia, transient dilation of the LV, LVEF post-stress & rest, and reversible regional wall motion abnormalities are other major indicators of poor prognosis (predictive parameters of cardiac events).
2012
Admitted to ER with atypical chest pain
Case presentation:
Female.
45 y.o.
Atypical chest pain, that has lasted for about 3 hours, stable.
She complains of fatigue and palpitations when exercising, however with no chest pain.
Smoker since 23 y.o.
Non diabetic.
Normal levels of blood pressure and cholesterol.
No history of CAD.
BMI 27, HR 78 bpm, BP 145/90 mmHg, normal chest examination, other wise unremarkable.
Basal EKG: pre-excitation syndrome. Cardiac enzymes including serum Troponine levels are within normal limits.
Basal echocardiogram: mild mitral valve prolapse, with preserved global and regional ventricular function.
Teaching points:
Attenuation is a common artifact in myocardial perfusion imaging, being present in 20-30% of cases, mimicking the presence of MI.
Breast attenuation causes pseudo-defects on the anterior wall of the left ventricle, and is more evident in women with lage breasts. However, it can be also significant in women with small but dense breasts. In men, diaphragmatic attenuation is more common, affecting the inferior wall - especially in obese patients.
Attenuation correction is possible using external sources or CT, but these are expensive solutions. Prone imaging can be used mainly for inferior wall artifacts.
Gated SPECT provides information about regional wall motion and thickening, which would be affected by infarction but preserved when attenuation is present.
Visualization of raw data can also aid in depicting attenuation.
2012
Atypical pain with positive CTA and normal MPI
Case presentation:
Female.
51 y.o.
Heavy family history of CAD, no other known risk factors.
Episodes of atypical chest discomfort. - Positive exercise test.
Submitted for CT angiography (CTA), reported as:Severe proximal LAD stenosis, no other lesions, Ca score >1000.
Teaching points:
CTA is sensitive for detecting CAD, however the technique has limited value in predicting the degree of stenosis.
Especially in the presence of arterial calcifications, it is sometimes difficult to assess the characteristics of a coronary lesion by CTA.
Calcium score >300 is associated with poor accuracy of CTA results (incomplete evaluation of coronary tree).
Myocardial perfusion has powerful prognostic value and is not affected by calcium score.