Negative Stress Test Is Not Always Negative: Revisiting the Clinical Implications of Balanced Ischemia

Area of Science:

• Cardiology
• Nuclear Medicine
• Diagnostic Imaging

Background:

• Myocardial perfusion imaging (MPI) using technetium (99mTc) sestamibi is a cornerstone in diagnosing coronary artery disease (CAD).
• Accurate MPI results guide critical clinical decisions, including revascularization strategies.
• The sensitivity of MPI can be limited, particularly in cases of balanced, diffuse, or multivessel coronary artery disease.

Observation:

• A case study involving a 45-year-old male patient with diagnosed severe coronary artery disease is presented.
• The patient underwent technetium (99mTc) sestamibi myocardial perfusion imaging as part of their diagnostic workup.
• Despite the presence of severe CAD, the MPI results were interpreted as normal, indicating a false-negative outcome.

Findings:

• The presented case demonstrates a false-negative myocardial perfusion imaging result in a patient with confirmed severe coronary artery disease.
• This false-negative finding occurred in the context of balanced perfusion deficits, a known limitation of MPI.
• The discrepancy between imaging findings and clinical severity underscores potential diagnostic challenges.

Implications:

• False-negative MPI results can lead to delayed diagnosis and suboptimal patient management for coronary artery disease.
• Clinicians must remain aware of the limitations of technetium (99mTc) sestamibi MPI, especially in patients with suspected or known multivessel disease.
• Further investigation or alternative diagnostic modalities may be warranted when clinical suspicion for CAD is high despite normal MPI findings.