False-negative myocardial scintigraphy in balanced three-vessel disease, revealed by coronary pressure measurement

Area of Science:

• Cardiology
• Nuclear Medicine
• Interventional Cardiology

Background:

• Myocardial perfusion imaging (MPI) is a common non-invasive test for diagnosing coronary artery disease (CAD).
• Balanced three-vessel disease, where all major coronary arteries have significant blockages, can sometimes lead to false-negative MPI results.
• This pitfall can delay diagnosis and treatment, potentially leading to adverse cardiac events.

Observation:

• A patient presented with typical chest pain suggestive of angina.
• Initial myocardial perfusion scintigraphy (MPI) results were negative, showing no significant ischemia.
• Coronary angiography revealed intermediate stenoses in the left anterior descending (LAD), left circumflex (LCX), and right coronary arteries (RCA).

Findings:

• Fractional flow reserve (FFR) measurements were performed to assess the functional significance of the coronary stenoses.
• FFR values of 0.54 (LAD), 0.56 (LCX), and 0.66 (RCA) unequivocally confirmed balanced three-vessel disease.
• These FFR values indicated that the intermediate stenoses were hemodynamically significant, despite the negative MPI.

Implications:

• This case underscores the limitation of MPI in detecting balanced three-vessel disease.
• Fractional flow reserve (FFR) is crucial for accurate diagnosis in equivocal cases of suspected CAD.
• Timely diagnosis and intervention, such as coronary artery bypass grafting (CABG), are essential for managing patients with significant multi-vessel CAD.