![Page 1: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/1.jpg)
Symptoms of heart failure with normal ECG
F. Mut, A. Beltran, M. Kapitan
Nuclear Medicine Service, Italian Hospital
& CUDIM
Montevideo, Uruguay
![Page 2: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/2.jpg)
Clinical history
• Woman 63 y.o.
• Overweight, hypertension, dyslipemia, type II diabetes.
• Mild/moderate renal insufficiency.
• 2 acute episodes of pulmonary edema 8-3 months before.
• Presents with chest pain and weakness after mild exercise.
• The rest ECG was totally normal.
• Medication: ARBS, diuretics, metformin, statins.
![Page 3: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/3.jpg)
• The patient was submitted for a stress-rest myocardial
perfusion study (MPS) with dipyridamole.
• 99mTc-MIBI two-day protocol was used (25 mCi, 925 MBq
each day), starting with the rest study.
• The stress test was well tolerated, with no ECG changes and
no symptoms, and normal BP response.
![Page 4: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/4.jpg)
MPS – qualitative result
![Page 5: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/5.jpg)
MPS – quantitative result (perfusion)
![Page 6: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/6.jpg)
MPS – quantitative result (LV function)
![Page 7: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/7.jpg)
The study result is consistent with:
a) Myocardial infarction with no ischemia
b) Myocardial infarction with ischemia
c) Hibernating myocardium and ischemia
d) b & c
![Page 8: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/8.jpg)
The study result is consistent with:
a) Myocardial infarction with no ischemia
b) Myocardial infarction with ischemia
c) Hibernating myocardium and ischemia
d) b & c
• There are reversible defects suggesting mild/moderate ischemia,
especially at the antero-lateral wall.
• Either myocardial infarction or hibernation, or a mixture of both,
could explain the fixed defects at the anterior, apical and inferior
walls.
• Since the patient had a normal ECG and the ischemic burden was
low, she was submitted for a viability study with 18F-FDG.
![Page 9: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/9.jpg)
PET with 18F-FDG
![Page 10: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/10.jpg)
Summary of perfusion/metabolic imaging
MIBI Dip
MIBI Rest
FDG
![Page 11: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/11.jpg)
How would you read the result?
a) Normal perfusion with abnormal metabolism
b) Abnormal perfusion with abnormal metabolism
c) Abnormal perfusion with normal metabolism
d) Normal perfusion with normal metabolism
![Page 12: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/12.jpg)
How would you read the result?
a) Normal perfusion with abnormal metabolism
b) Abnormal perfusion with abnormal metabolism
c) Abnormal perfusion with normal metabolism
d) Normal perfusion with normal metabolism
• This is a perfusion-metabolism mismatch, consistent with
myocardial hibernation.
• Since there is evidence of viability, revascularization is warranted.
• Of note, the patient could have probably been sent for
catheterization anyway since there was some evidence of
ischemia in the stresss/rest MIBI study.
![Page 13: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/13.jpg)
Follow-up
• The patient was sent to catheterization.
• Three-vessel disease was observed with diffuse lesions and
thin arteries.
• Not a candidate for revascularization due to technical
limitations.
• She was put on aggressive medical treatment with some
clinical improvement at 6 months follow-up.
![Page 14: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/14.jpg)
Teaching points
• Myocardial viability assessment is indicated in patients with
chronic LV dysfunction.
• In patients with LV dysfunction and myocardial viability, the
mortality is significantly lower in those treated with
revascularization than those treated medically.
• The extent of perfusion–metabolism mismatch is proportional to
mortality rate in medically treated patients with chronic ischemic
LV dysfunction.
![Page 15: Symptoms of heart failure with normal ECG · Symptoms of heart failure with normal ECG F. Mut, A. Beltran, M. Kapitan Nuclear Medicine Service, Italian Hospital & CUDIM Montevideo,](https://reader030.vdocuments.us/reader030/viewer/2022040811/5e53881f59c9ca15f45e6428/html5/thumbnails/15.jpg)
• Braunwald E, Rutherford JD. Reversible ischemic left ventricular
dysfunction: evidence for ‘hibernating’ myocardium. J Am Coll Cardiol
1986; 8:1467–70.
• Dilsizian V, Bonow RO. Current diagnostic techniques of assessing
myocardial viability in hibernating and stunned myocardium. Circulation
1993; 87:1–20.
• Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Myocardial viability
testing and impact of revascularization on prognosis in patients with
coronary artery disease and left ventricular dysfunction: a meta-
analysis. J Am Coll Cardiol 2002; 39:1151–8.
• Desideri A, Cortigiani L, Christen AI, et al. The extent of perfusion–F18-
FDG PET mismatch determines mortality in medically treated patients
with chronic ischemic left ventricular dysfunction. J Am Coll Cardiol
2005; 46:1264-9.
Bibliography