Case Presentation Corner13N-Ammonia myocardial blood flow quantitation in patient with aneurismal coronary artery disease
Introduction
Aneurysmal coronary artery disease (ACAD) is a vascular phenotype that is observed infrequently in patients who undergo coronary angiography (CA),1 includes coronary artery aneurysms (CAA) and coronary artery ectasia (CAE).2 Clinical presentations range from an incidental finding on cardiac imaging to an acute coronary syndrome.3 Poor long-term outcomes are associated with CAA or CAE. Management of these patients presents a dilemma to the clinician due to the lack of randomized trials.
Noninvasive functional studies are not usually considered as a routine ACAD approach. Our report suggests that 13N-ammonia PET/CT myocardial perfusion imaging study (MPI) should be mandatory because it demonstrates hemodynamic alterations that are not routinely assessable in the angiographic study. These findings allow defining a more appropriate therapeutic management.
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Case report
A 45-year-old male presented to the emergency department with typical acute oppressive chest pain and dyspnea in the last five hours. His past medical history included smoking habits, hypertension, dyslipidemia, and familiar history of coronary artery disease. No previous cardiac history was known.
His physical exam, electrocardiogram and cardiac biomarkers (high sensitive troponins) were normal; diagnosis of unstable angina was made. Despite treatment with nitrates, the patient continued with
Discussion
CAA is defined as a localized irreversible dilatation of the coronary vascular lumen with a diameter ≥ 1.5 times that of the adjacent normal coronary segment. CAE describes diffuse dilatation of the coronary arteries that involves ≥ 50% of the artery’s length.2,4 Both conditions can be simultaneously present, generating disturbed coronary blood flow, which potentially promotes thrombogenicity and inflammatory reactions associated with coronary artery disease.5
The reported prevalence of ACAD
Conclusions
Controversies regarding the optimal approach to ACAD persist. Although coronary angiography is the standard study of choice to characterize anatomical coronary abnormalities, these patients must be studied with a noninvasive imaging to evaluate their functional impact. In our case, the use of 13N-ammonia PET/CT MPI to assess the degree of ischemia and the CBF and CFR reduction helped determine the CAA’s functional impact. We suggest that PET/CT MPI with flow quantitation should be mandatory in
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