30 Oct

New Exercise Parameter for the Identification of Severe Coronary Artery Disease: Case Report

Case Report
The patient is a 60-year-old white man with a history of insulin-dependent diabetes mellitus, hypertension, and two prior non-q-wave myocardial infarctions. The patient also has exertional angina usually relieved by rest and sublingual nitroglycerin. Cardiac catheterization had revealed significant three-vessel coronary artery disease; mid-left circumflex artery lesion (80 percent), proximal right coronary artery lesion (75 percent), and a 60 percent lesion in the diagonal branch of the left anterior descending artery (Fig 1). review

The left ventriculogram revealed an ejection fraction of 79 percent with normal systolic function. Despite a progressive increase in medical therapy, his anginal symptoms continued, and exercise thallium 201 scintigraphy was performed to evaluate the extent and severity of ischemia. At the time of investigation, the patient was receiving diltiazem, 240 mg daily; Nitrobid, 36 mg daily; prazosin, 18 mg daily; and aspirin, 300 mg daily. The patient was exercised on a standard Bruce protocol, and the test was terminated secondary to leg fatigue at 4 minutes and 46 seconds. He had no chest pain or shortness of breath during or after the test. Also, no diagnostic ST segment depression was achieved either during exercise or the recovery period (Fig 2). The patient achieved a peak heart rate of 108 beats per minute (65 percent of maximum predicted) and a peak blood pressure of 154/74 mm Hg giving a double product of 166. At one minute prior to termination, the patient received an intravenous injection of 1.92 mCi of thallium 201 radioisotope. The 1, 2, and 3 minute recovery period blood pressure measurements were respectively 138/52, 148/54, and 158/56 mm Hg giving rise to 1, 2, and 3 minute systolic blood pressure recovery ratios of 0.90, 0.96, and 1.02, respectively.

Figure 1. Angiographic findings demonstrating a 75 percent lesion in the proximal right coronary artery 1, upper. Lower portion reveals significant lesions in the circumflex artery and the diagonal branch of the left anterior descending artery.

Figure 1. Angiographic findings demonstrating a 75 percent lesion in the proximal right coronary artery 1, upper. Lower portion reveals significant lesions in the circumflex artery and the diagonal branch of the left anterior descending artery.

Figure 2. Exercise electrocardiographic findings at baseline (standing hyperventilation), peak exercise and during the recovery period. The patient has baseline ST-segment depression that does not achieve diagnostic criteria.

Figure 2. Exercise electrocardiographic findings at baseline (standing hyperventilation), peak exercise and during the recovery period. The patient has baseline ST-segment depression that does not achieve diagnostic criteria.

Categories: Coronary Artery
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