The dilemma of ischemia testing with different methods

Area of Science:

• Cardiovascular Imaging
• Non-invasive Cardiac Diagnostics
• Coronary Artery Disease (CAD) Detection

Background:

• Pharmacologic stress testing is crucial for diagnosing coronary artery disease (CAD).
• Traditional stress echocardiography relies on wall motion analysis, which can be insensitive to multivessel disease.
• Adenosine cardiac magnetic resonance (aCMR) is a recognized imaging modality for CAD detection.

Observation:

• A 52-year-old man with effort angina presented with normal treadmill ECG but positive aCMR for left anterior descending (LAD) territory perfusion defects.
• Contrast high-dose dipyridamole stress echocardiography (cSE) revealed perfusion defects in lateral and apical segments, alongside reduced LAD flow reserve.
• Wall motion analysis during cSE and treadmill ECG was normal, while aCMR only identified LAD disease.

Findings:

• cSE with myocardial perfusion (MP) assessment detected both LAD and circumflex obstructive lesions, surpassing the sensitivity of wall motion assessment.
• MP analysis during cSE demonstrated multivessel subendocardial perfusion defects, a key marker for balanced CAD.
• Doppler measurement of coronary flow reserve further supported the detection of obstructive CAD.

Implications:

• Myocardial perfusion assessment during cSE overcomes the limitations of wall motion analysis in detecting multivessel CAD and balanced ischemia.
• Advanced echocardiographic techniques, particularly MP analysis, can provide more comprehensive results than aCMR in selected cases.
• cSE with MP assessment is a valuable tool for identifying significant multivessel obstructive CAD, a finding with dismal prognostic implications.