Cardiology Case 1
Dr. Smita Chinmay Kulkarni, DNB (Nucl Med), FEBNM, MNAMS
Department of Nuclear Medicine and Molecular Imaging,
Amrita Institute of Medical Sciences,
Kochi, Kerala, India
53 year old post menopausal lady, known case of T2 DM and dyslipidaemia on medication, presents to cardiology OP with DOE (Dyspnoea on Exertion) grade 2 since 2 months, with intermittent sharp pricking type chest pain, lasting for few seconds, not related to physical activity, or food consumption. Her resting ECG shows, regular rhythm, widened QRS complex and no evidence of pathological Q waves. 2D Echocardiography shows paradoxical motion of interventricular septum and LVEF of 60%. According to ACC/AHA guidelines what is the next appropriate investigation for this patient?
- Invasive coronary angiography
- Treadmill exercise stress testing
- Stress-Rest Myocardial Perfusion scintigraphy with exercise stress testing.
- Pharmacological stress testing using adenosine and myocardial perfusion scintigraphy.
- Pharmacological stress testing using dobutamine and myocardial perfusion scintigraphy.
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Ans. D. Pharmacological stress testing using adenosine and myocardial perfusion scintigraphy.
Explanation: Based on age, gender and symptoms, the above mentioned patient can be classified under the intermediate risk group according to Framingham risk stratification, and the chest pain can be described as atypical angina. According to ACC/AHA guidelines, in intermediate risk group, if there are no signs of ischemia on resting ECG, the next appropriate step is a stress-rest myocardial scintigraphy (MPS), to look for inducible ischemia. Invasive coronary angiography is most suitable for high risk group and exercise stress testing (TMT) is indicated in low risk group. MPS can be done using exercise stress testing or pharmacological stressing. Note should be made that the above patient’s ECG and ECHO show findings of left bundle branch block (LBBB). According to ACNC imaging guidelines, the stress testing related to chronotropic effects of the heart like exercise stress testing or pharmacological stress using dobutamine, should not be done for performing MPS to avoid misinterpretation of MPS scans.
- Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/ SCMR/SNM 2009 Appropriate Use criteria for Cardiac Radionuclide Imaging. J Am Coll Cardiol 2009; doi: 10.1016/j.jacc.2009.02.013.
- Morise AP, Haddad WJ, Beckner D. Development and validation of a clinical score to estimate the probability of coronary artery disease in men and women presenting with suspected coronary disease. Am J Med1997;102:350-6.