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Number 09-01: Is it or isn’t it coronary artery disease?

Case from: Anna Herrey, Ajay Suri, Andrew Flett, Simon Woldman, The Heart Hospital, London, UK

History: A 46-year-old man presents with breathlessness, heart failure and chest pain. Troponin borderline

Past medical history: Diffuse coronary artery disease 3 year previously; systemic lupus with persistent pleural effusion and joint pains.

Echo: globally poor systolic function, borderline AV dyssynchrony SPECT: ‘minimal inducible ischaemia’

Angiography: delayed as too unwell.

CMR requested, question: ischaemic cardiomyopathy?

* note: cine artefact was determined to be due to the surface coil connection

Cine CMR: Marked dilatation and regional dysfunction* (inferior and infero-lateral dyskinesis with preserved myocardial thickness)

Contrast CMR: absence of LGE suggests viability of all territories CMR diagnosis: Likely stunning of infero-septal and inferior wall. Consider angio. The possibility of thrombus in a dominant RCA exists…

Coronary angiography: A dominant RCA with thrombus – treated with successful PCI

Follow-up CMR: six weeks later: significant regional and global LV recovery (+20% ef) confirming stunning of the inferior and infero-septal wall. No infarction from the procedure

PRE PCI

POST PCI

Conclusion: CMR accurately predicted the presence of acute coronary disease as well as recoverability of the affected coronary territories.

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