Severe transmural myocardial ischemia after dipyridamole administration implicating coronary steal

Myocardial perfusion imaging with coronary vasodilators is routinely used for patients with suspected coronary disease who are unable to exercise. Since these agents work by increasing blood flow without significantly changing myocardial oxygen demand, they generally do not produce ischemia. A minority of patients show evidence of ischemia which some investigators suggest is due to a coronary steal phenomenon, but this has been challenged by several investigators. We present the case of a patient who developed severe transmural myocardial ischemia manifested by ST-segment elevation and severe perfusion defects which occurred after dipyridamole administration and which were reversed with aminophylline and nitroglycerin. This case supports the notion that coronary vasodilation with dipyridamole can induce a coronary steal.