CASE 5529 Published on 15.01.2007
0

Coronary artery disease - Perfusion

Section

Cardiovascular

Case Type

Clinical Cases

Authors

Kokocinski T, Nagel E. German Heart Institute Berlin and cmr-academy 13353 Berlin, Germany

Connected authors
Patient

54 years, male

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Clinical History
Presenting with atypical angina pectoris
Imaging Findings
Patient is presenting to the outpatient department with atypical angina pectoris. Risk factors are arterial hypertension and hyperlipoproteinemia. Ambiguous exercise ECG due to left ventricular hypertrophy. Stress MR imaging was ordered due to insufficient echocardiographic image quality. MR imaging consisted of wall motion at rest, adenosine stress perfusion (140µg adenosine /kg body weight for 4 minutes, 0.05 mmol Gd-DTPA-BOPTA/kg body weight), rest perfusion after 10 minutes (0.05 mmol Gd-DTPA-BOPTA/kg body weight), and late Gd enhancement after 10 minutes. Wall motion showed a resting wall motion abnormality basal and equatorial inferior and inferolateral (Figure 1). Perfusion imaging showed an adenosine induced defect in the apical anterior, apical septal, apical inferior and equatorial septal segments (Figure 2=rest; Figure 3=stress). Basal and equatorial inferolateral hypoperfusion is suspected also in the resting perfusion images. Late Gd enhancement shows inferior and inferolateral scar tissue in the equatorial and basal segments (Figure 4). A significant stenosis of the LAD and the RCA was diagnosed from MR imaging. An infarction in the segments usually supplied by the RCA and partially LCX was found. The area of ischemia was larger, than the area of infarction. A proximal high grade stenosis of the RCA, LAD and RCX was diagnosed by invasive angiography (Figure 5+6).
Discussion
Male patients aged 50-59 with atypical angina pectoris have an intermediate pre-test probability (10 – 90%) for significant coronary artery disease. Atypical angina pectoris is defined as substernal chest pain of discomfort that is either provoked by exertion or emotion at stress or relieved by rest and / or nitroglycerin (but not both). In such patients stress testing is required to determine the presence of significant coronary artery disease. Diagnosis of ischemia can be performed with several tests, usually starting with exercise ECG, followed by nuclear techniques (SPECT) or stress echocardiography. In patients with left ventricular hypertrophy due to long-standing hypertension, exercise ECG is frequently non-diagnostic. In ambiguous cases or moderate image quality MR stress testing is appropriate, either using dobutamine stress wall motion assessment or adenosine stress perfusion imaging. The patient shows a previously unknown myocardial infarction and additional stress induced ischemia which clearly extends to a larger area than the infarcted tissue. In any case (unknown infarction or ischemia) the patient should be assessed with invasive angiography to fully understand the coronary status.
Differential Diagnosis List
Triple vessel disease. Inferolateral myocardial infarction.
Final Diagnosis
Triple vessel disease. Inferolateral myocardial infarction.
Case information
URL: https://eurorad.org/case/5529
DOI: 10.1594/EURORAD/CASE.5529
ISSN: 1563-4086
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