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Updated: Jun 16, 2026
In Vivo Quantitative Assessment of Myocardial Structure, Function, Perfusion and Viability Using Cardiac Micro-computed Tomography
Published on: February 16, 2016
Incidental detection of apical hypertrophic cardiomyopathy by myocardial perfusion imaging
Richard Bruce Irwin1, Parthiban Arumugam, Rajdeep S Khattar
1Manchester Heart Centre, Manchester Royal Infirmary, Manchester, UK. rbirwin@hotmail.com
Insights
Diagnosing apical hypertrophic cardiomyopathy (HCM) can be challenging with standard echocardiography. Myocardial perfusion imaging may reveal increased apical tracer uptake, suggesting HCM and prompting further investigation.
Area of Science:
- Cardiology
- Medical Imaging
- Nuclear Cardiology
Background:
- Echocardiography is standard for hypertrophic cardiomyopathy (HCM) diagnosis.
- Apical HCM can be missed due to imaging limitations and low clinical suspicion.
- Patients may undergo single-photon emission computed tomography (SPECT) imaging for undiagnosed chest pain.
Observation:
- Three cases of apical HCM were initially suspected via myocardial perfusion imaging.
- Patients presented with chest pain, initially undiagnosed by echocardiography.
- Adenosine stress rest technetium-99m tetrofosmin SPECT revealed increased apical tracer uptake.
Findings:
- SPECT showed marked tracer uptake in the apical myocardium.
- Two patients exhibited apical hypokinesia on gated SPECT.
- Transpulmonary contrast echocardiography confirmed apical HCM in all cases.
Implications:
- Increased apical tracer uptake on perfusion imaging suggests apical HCM.
- Contrast echocardiography is crucial for diagnosing apical HCM.
- Physicians should consider apical HCM when perfusion imaging shows apical abnormalities.
Background:
Echocardiography plays a central role in the diagnosis of hypertrophic cardiomyopathy (HCM). However, apical involvement of HCM may be missed because of foreshortening and inadequate clinical suspicion. These patients may be referred for single-photon emission computed tomography imaging.
Methods:
We present three cases of HCM predominantly involving the cardiac apex, whose diagnosis was first suspected on myocardial perfusion imaging. These patients were referred for chest pain syndromes to exclude significant coronary artery disease. All were undiagnosed on initial routine transthoracic echocardiography, and none were specifically suspected by the referring clinicians. All cases underwent an adenosine stress rest technetium-99m tetrofosmin myocardial perfusion protocol, and were subsequently referred for transpulmonary contrast echocardiography.
Results:
Single-photon emission computed tomography imaging revealed increased tracer uptake in all cases, most marked in the apical myocardium. Inferior wall ischaemia was detected in one case, consistent with a coronary stenosis seen at angiography. Apical hypokinesia was noted in two patients on gated studies. Contrast echocardiography confirmed the diagnosis of HCM with apical involvement in all cases.
Conclusion:
Echocardiography is the first-line imaging technique for the diagnosis of HCM, but apical involvement may be missed unless a contrast study is performed. The presence of increased apical tracer uptake on perfusion imaging should alert the referring physician to the possibility of apical HCM, irrespective of earlier echocardiographic findings.
