NUCLEAR CASES

1.181-60-69 (12/10/2011)
• 71 female
• HTN, obese and OA
• IPMI Feb 2010 (late for streptokinase)
• LHC: LM normal, LAD 80-90% severe stenosis after D1, D1 ;large
vessel with 90% severe proximal stenosis, LCX normal, RCA
plaquing, PLV distal 100%
• Failed PCI to LAD so treated medically
• Refer for MPS because she has mild exertional chest pain 15-20
days back which relieved at rest
• Scan was done with persantine
 Reprted as
• 1. Large sized, severe inferior and
inferoapical infarct with no ischemia during
pharmacological myocardial perfusion
imaging without any chest discomfort or
ECG changes diagnostic of ischemia.
 2.230-41-56 (12/10/2011)
• 43 male dyslipis
• Cath 2vd (LAD, OM) secondary to chest pain (record
N/A)
• C/O bilateral chest burnig which radiate to right arm
associated with exertion, relieved own its own with rest
and S/L GTN and sometime it remain for 3-4 hours
• Exercise for 6:23min
• Stage III
• METS 7.7
• Stop for chest pain and NSVT
 Reported as
• 1. Large size severe, anterior, apical and
septal ischemia.
• 2. Large size area of moderate-to-severe
lateral ischemia.
• 3. Stress induced cavity dilatation noted.
• 4. Severely reduced left ventricular
dysfunction.
• 5.Above findings are associated with
angina and nonsustained VT.
 3.P242716
• 60 male
• HTN dyslipid
• No prior history of MI
• C/O chest heaviness on emotional stimulus which has
no exertional relationship, never use S/L GTN
• Exercise for 7 min
• Stop for fatigue
• Heart rate 81% of MPHR
• METS 7.2
 Reported as
• . Large sized, severe inferior and
inferoapical infarct with no ischemia during
exercise myocardial perfusion imaging at
81% of the maximum predicted heart rate
and 7.2 METS without any chest
discomfort or ECG changes diagnostic of
ischemia.
• 2.Dilated LV cavity with mild LV
dysfunction
 4.017-46-50 (12/10/2011)
• 61 male
• HTN cabg ’98 secondary to IWMI
• Cor angio in ’03 Severe 3 VCAD, patent LIMA to LAD, SVG
to OM2 and occluded SVG to OM1/RCA
• Complain of chest pain on exertion about ½ KM fo brisk
walk relieved with rest
• Exercise for 4:33min
• Stop for chest pain similar to his prior symptoms
• METS 6.4
• 83% of MPHR
•
 Reported as
• 1. Large sized, severe inferior and
inferolateral infarct with no ischemia during
exercise myocardial perfusion imaging at
83% of the maximum predicted heart rate
and 6.4 METS without any chest
discomfort or ECG changes diagnostic of
ischemia.
 5.142-41-55 (5/10/2011)
• 55 male
• CABG ’03 and PCI ’03 secondary to USAP
• MPS for regular checkup
• Exercise for 9:35 min
• Stop for fatigue
• MMETS 11
• 855 of MPHR
 Reported as
• 1. Large sized, severe inferior and
inferolateral infarct without ischemia
during exercise myocardial perfusion
imaging at 85% of the maximum predicted
heart rate and 11 METS without any chest
discomfort or ECG changes diagnostic of
ischemia.
• 2. Mildly reduced left ventricular
dysfunction.
 6.Shfquat ghafoor shah
• 51 male
• AWMI ’00 PCI to Lad @ Peshawar
• MPS for routine
• Walk 6-7 KM daily briskly w/o and sx
• Exercise 12min
• Stop fatigue
• HR 98% MPHR
• METS 13.5
• No Sx
Scan
Reprted as
 7.Haji JilanI
• 58 male
• Diabetes
• Hypertension
• Smoling
• Naswar
• Had severe Chest pain 20 days back in Quetta received streptokinase
(no recorrd available)
• Now walk daily for 2 hours w/o Sx
• Exercise for 6:30 min
• Stop fatigue
• METS 7.7
• HR 88% MPHR
• No chest pain
scan
 Reported as
• 1. Large sized, severe inferior infarct with
no ischemia during exercise myocardial
perfusion imaging at 88% of the maximum
predicted heart rate and 7.2 METS without
any chest discomfort or ECG changes
diagnostic of ischemia.
• 2. Mildly reduced left ventricular
dysfunction.
 8.Rasheed khan
• 69 male
• Had MI ’88
• Severe LV dysfuction
• HTN admitted with decompesated heart failure
• MPS was done for ischemia and viability with nitrate
• Walk daily for 4 km with no chest pain
• Scan was done with persantine
scan
 Reported as
• 1. Large sized, severe anterior, apical and
septal infarct with no ischemia during
pharmacological myocardial perfusion
imaging without any chest discomfort or
ECG changes diagnostic of ischemia.
• 2. Severely reduced left ventricular
dysfunction.
 9.Mohd shabuddin suleman
• 43 male
• DM
• HTN
• Has shortness of breath on exertion 2 year back echo was dine
showed EF was 45% put on medical treatment
• Had atypical chest pain 2 weeks back echo was done now showed
EF 15%, all segments are akinetic except basal lateral, basal
posterior and basal lateral wall
• Was advised CathAdvised CABG
• Came to Dr shahid sami, who advised him to get MPSHe exercise
for 4:25min
• Stop for SOB
• Achieved 5.2 METS acitivity and 82% MPHR
• No chest pain
scan
 Reported as
• 1. Large sized severe anterior and apical
ischemia.
• 2. Large sized inferolateral myocardial
infarct with moderate periinfarct ischemia.
• 3.Dilated LV cavity with severe LV
dysfunction.
 10.
• 50 years male
• DM/HTN/Dyslipid/smoler
• SOB on exertion on ½ KM walk
• denies prior H/x of IHD on repeated questioning
• Exercise for 5:30 min
• Stop fatigue
• Achieved 7 METS activity and 81% of MPHR
• Complain on shortness of breath but no chest
pain
Scan
 Reported as
• 1. Medium sized, partial thickness,
moderate anterior and apical infarct with
no ischemia during exercise myocardial
perfusion imaging at 81% of the maximum
predicted heart rate and 7 METS without
any chest discomfort.
• 2. Severely reduced left ventricular
dysfunction.
 11.Nagori hafiz anwar
• 82 male had CABG ’06 LIMA to LAD, SVG to OM and RCA
• Was admitted with NSTEMI and CHF in ’07
• Cath was done showed LAD proximal 90% distal 70% distal to
anastomosis, Ramus proximal 90% distal branch prox 100%, RCA
prox 70% and mid 40%
• LIMA to Lad patent, SVG tyo lower branch of ramus patent
• SVG to PDA with 90% at distal anastomosisNow referred for MPS
for preop risk stratification for Ca cheek resection
• Functional activity limited
• No chest and and SOB
• Scan was done with parsentine
scan
 Reported as
• 1. Large sized area of moderate-to-severe
inducible ischemia in the anterior and
apical territory during pharmacological
myocardial perfusion imaging without any
chest discomfort or ECG changes
diagnostic of ischemia.
 12.Arshad Iqbal
• 29 male
• Police officer
• DM/HTN/FH positive for premature CAD
• C/ O left sided chest pain non radiating localize
• Referred for MPS for ischemai evaluation
• Exercise for 9:45 min
 Reported as
• 1. Large sized area of moderate inducible
ischemia in the apical and anteroseptal
territory during exercise myocardial
perfusion imaging at 88% of the maximum
predicted heart rate and 11 METS without
ECG changes diagnostic of ischemia.
Patient complain of mild chest discomfort.
 13.Ghazanfar, Ali Ahmed
• 40 male
• Dyslipid, smoker
• Coronary angio secondary to chest pain outside AKUH 2
years back told to be normal ( Record N/A)
• Now with left arm and left sided chest pain 2 weeks
back, no exertional relationship, relief own it’s own,
never use S/L GTN
• Exercise for 9 min, achieved 80% of MPHR at 10.2
METS activity in stage 4
• Had chest pain during exercise and that was limiting
Scan
Reported as
 14.Abdul Sattar Dairy
• 38 male
• DM/HTN/CKD/Smoker
• History of Lt BKA secondary to diabetic
foot
• Indication is preop for left BKA stump
revision
• Stress was done with persantine
Scan
 Reported as
• 1. Large sized, severe inferolateral infarct
with no ischemia during pharmacological
myocardial perfusion imaging without any
chest discomfort or ECG changes
diagnostic of ischemia.
 15.Khair mohd Zardari
• 65 male
• DM/HTN/Dyslipid/Alcohol
• Ex-smoker
• C/o ghabrahat and sweating w/o any chest pain
and SOB
• Exercise for 6 min and stop for fatigue achieved
93% of MPHR at 7 METS activity
• No chest pain
Reported as
 16.Memon Jan Mohd Tayyab

• 76 male HTN/Smoker/Dyslipid/Asthma
• Doing regular and and exercise
• Now C/o pain in Left arm on exertion but
get relieved on rest, but no chest pain,
never use S/L angisid
• Exercise for 6 min and 30 seconds and
stop for fatigue, achieved 83% on MPHR
on 7.7 METS but no chest pain
scan
Reported as
 17.Nuclear Case
o 83 male
o Had CVA 25 years back (recovered)
o Tobacco chewer
o Severe LV dysfunction
o Refer for preop risk stratification for TURP
and hernia repair
o Pharmacological stress was done with
persantine
baseline
peak
 Reported as
• Large size moderate intensity inferior
defect without ischemia
• Large size septal defect could be due to
LBBB
• Dilated LV with severe LV dysfunction
• EF 20%
 18.P218751
• 43 male
• DM/HTN/smoker
• Severe central chest pain for 8 hours
• Given Streptokinase in LNH pain settled
• Now referred for viability assessment
• Test was done with persantine
Baseline
Peak
Scan P218751
 Reported As
• SPECT cardiac perfusion scan with
dipyridamole intervention is negative for
inducible ischemia.
• There is evidence of a medium size fixed
perfusion defect of high severity involving
apex, apical and mid cavity anteroseptal
wall with evidence of apical aneurysm.
This represents full thickness infarction of
LAD teritory.
 19.216-43-25
• 50 male
• DM/ Dyslipdemic /tobacco chewer/ Ex-smoker quitted 4 years back
• C/O of left sided chest pain on mild exertion since 4 years
nonradiating, get relieved on rest never took S/L GTN
• ETT was done
– Walked for 3 min, end point was chest pain
– Achieved 59% of MPHR @ 5METS
– At peak exercise no significant ST/T changes noted, but frequent PVC
were noted
– DTS -5.0

– Stress was done with persantine

– Developed left sided chest pain similar to his previous symptoms during
stress which relieved after 10 min in recovery
Baseline
Peak
 Reported as
• GSPECT cardiac perfusion scan with
dipyridamole intervention reveals a small
size inducible ischemia of moderate
severity involving apex and apical anterior
wall with normal LV function.
 20.P218604
• 55 male
• DM/HTN/smoking/FH+
• Had IMI Oct ’06 primary PCI to RCA in Tabba hospital
• For further episode of chest pain since then
• Now referred for ischemia on meds
• Walked for 7min 11sec achieved 73% of MPHR
• Stopped secondary to chest heaviness different from his
previous symptoms and shortness of breath
• Achieved 8.8 METS
• Chest heaviness relieved 2 min in recovery without any
intervention
Baseline
Peak
 Reported as
• Exercise SPECT cardiac perfusion scan at
73% predicted HR and 8.8 METS is
negative for inducible ischemia.
• There is evidence of a medium size fixed
perfusion defect of high severity involving
inferior and distal inferolateral wall.
 21.189-95-05
• 68 female
• DM/HTN/IHD/osteoarthritis
• S/P PCI to LAD in 2008 @ Tabba heart
institute
• C/O left chest heaviness on mild exertion
relieved by S/L GTN but symptoms are
different from previous episode
• Pharmacological stress was done with
persentin
• Small size, moderate intensity, partial
thickness fixed apical perfusion defect w/o
ischemia
 22.153-80-55
• 81 male
• S/P IWMI ’07
• Walked daily for >1hour with no symptoms
• Now reffered for MPS for efficacy of
treatment
• Exercise for 5 min and 46 sec
• Stopped for fatigue
• Achieved 7 METS
 Reported as
• Large sized, severe inferolateral and lateral
infarct during exercise myocardial perfusion
imaging at 135% of the maximum predicted
heart rate and 7 METS without any chest
discomfort or ECG changes diagnostic of
ischemia.
• Baseline cavity dilation
• Lateral severe hypokinetic
• Rest hypokinetic
• Severely reduced left ventricular dysfunction.
 23.137-96-13
• 48 male
• HTN/Dyslipid
• S/P Anterior MI Aug `09 PCI to LAD @ Tabba hospital
• Developed sinking feeling rellok LHC was done in Jan
`10- patent stent
• Now again c/o sinking feeling along wit mild left sided
chest pain
• Exercise for 9 min and 30 sec stopped for fatigue
• Achieved 75% of MPHR and 11 METS
•
Baseline
Peak
 Reported as
• Large sized, severe anterior, apical and
septal infarct without ischaemia during
exercise myocardial perfusion imaging at
75% of the maximum predicted heart rate
and 11 METS without any chest
discomfort or ECG changes diagnostic of
ischemia.
 24.217-52-20
• 48 yrs female
• Had typical chest pain 2 months back when to some
local doctor in Afghanistan got some treatment ( record
N/A)
• LHC which showed SVCAD (LAD 50-60%)
• LVEF 45%
• So referred of functional significance of lesion
• Exercise for 7 min 55 sec
• Stopped for fatigue
• Achieved 92% of MPHR and 10 METS
baseline
peak
• Medium sized, moderate anterior, apical
and septal infarct without ischaemia during
exercise myocardial perfusion imaging at
92% of the maximum predicted heart rate
and 10 METS without any chest
discomfort or ECG changes diagnostic of
ischemia
 26.180-72-29
• 62 male
• S/P PCI 2003 twice secondary to USAP outside AKU (no record available)
• FC1, can walk upto 2 miles
• Now with left chest pain different from previous symptoms although get
relieved by S/L GTN
• Referred for MPS
• Walked for 5:05 min, achieved heart rate of 115/min (70%) of MPHR
• Achieved 7 METS
• At peak exercise complaining of chest pain same as previous symptom
• ECG showed 2mm STE in aVR, 1mm STE in aVL and V1, and 3mm
horizontal STD in II, III, V3-V6
• DTS -18 (high risk)
baseline
peak
Recover 10 min
 Reported as
• Medium size, moderate intensity, partial
thickness inferior ischemia
• Gated images after stress shows inferior
hypokinesis with calculated EF 60%
 27.189-86-43
• 62 male
• HTN
• c/o mild to moderate central chest pain
• Referred for MPS for diagnosis of chest
pain
• Exercise for 5 min 02 sec
• Achieved 101% of MPHR and 7.0 METS
• Stopped for fatigue
baseline
peak
 Reported as
• Large sized area of severe inducible
ischemia in the apical and anteroseptal
territory during exercise myocardial
perfusion imaging at 101% of the
maximum predicted heart rate and 7
METS with chest discomfort or ECG
changes diagnostic of ischemia.
• Stress induced cavity dilatation noted
LHC was done on 4/08/10
 28.070-19-74
• 62 years, male
• DM/HTN/Dyslipid
• CABG 1990
– LIMA to LAD
– SVG to PDA, PLV, OM and ramus intermedius
• Had coronary angio done ( 06/08/2010)
– Right dominant system
– Left main coronary artery plaquing
– Proximal LAD 100%
– Mid LAD fills via LIMA
– D1 fills via LIMA
– Proximal Left circumflex artery plaquing
– OM1 100%
– Heavily calcified , ectatic proximal RCA 20-30%
– Mid RCA 80%
– Distal 20-30%
– RPDA fills from collaterals from LAD

• Referred for MPS for significance of lesion and ischemia on medsBaseline ECG shows Q in III
and aVF
• Exercise for 9 min and 40 sec achieved 11 METS and 64% of MPHR
• Stopped for fatigue
 Reported as
• Small sized area of mild inducible
ischemia in the inferolateral territory during
exercise myocardial perfusion imaging at
64% of the maximum predicted heart rate
and 11 METS without any chest
discomfort or ECG changes diagnostic of
ischemia
• Normal left ventricular ejection fraction