Should You Consider Cardiac Catheterization for Myocardial Ischemia?

Is cardiac catheterization necessary for myocardial ischemia?

Hello Doctor, a few days ago I went to see a cardiologist because I experienced shortness of breath while sitting.
After performing an exercise stress test, the doctor informed me that I have myocardial ischemia and ordered a myocardial perfusion imaging study.
The report results are as follows:
1.
Area of perfusion defects in the anterior, inferior, and inferoseptal walls (score 2-3) of the left ventricle (LV) during the treadmill stress phase, with partial recovery of perfusion in the same sites after rest redistribution.
(Post-stress left ventricular ejection fraction (LVEF) = 68%, rest LVEF = 67%, normal > 50%, stress perfusion defect area is 11% of coronary territory, and reversibility is 91% of the perfusion defect).

2.
The lung-heart ratio during stress and rest is 0.32 and 0.36, respectively (normal < 0.5).
The transient ischemic dilatation (TID) of the LV is 0.71 (normal < 1.1).

3.
Semiquantitative 17-segment analysis of myocardial perfusion in the LV yielded a summed stress score (SSS) of 14.
(SSS 1-3: normal, 4-8: mildly abnormal, 13 and above: severely abnormal).

4.
The 5-point scoring system is as follows: 0—normal, 1—mild reduction of uptake (not definitely abnormal), 2—moderate reduction (definitely abnormal), 3—severe reduction of uptake, 4—absent uptake.
(J Nucl Cardiol 2009;16:165).

Conclusion:
1.
Myocardial ischemia in the anterior, inferior, and inferoseptal walls (definitely abnormal, severe reduction of uptake) of the LV was demonstrated.
SSS > 13 indicates high risk.

2.
Follow-up examination is recommended.

3.
The overall sensitivity is about 80% to 90%.
(Essentials of NM and Molecular Imaging 2019;5:146).

Here are the images from the scan: https://imgur.com/a/bXfz9Xt?third_party=1#_=_
I do not have hypertension, diabetes, or hyperlipidemia, and my blood tests show no abnormalities.
However, four years ago, I was diagnosed with mitral valve prolapse and tricuspid regurgitation, and I tend to get anxious, which also causes shortness of breath.
At that time, the exercise stress test was negative.
The doctor prescribed me a pink beta-blocker.
Could the mitral valve prolapse be causing the myocardial ischemia? My symptoms include wanting to take a deep breath while sitting, but I don't have much trouble when I jog; I can run without feeling breathless.
However, I experience significant shortness of breath after drinking coffee or tea.

Do I definitely need to undergo a cardiac catheterization after this? Additionally, after the echocardiogram, the doctor said my blood flow was normal, yet I still have myocardial ischemia, which I find a bit strange since I just had the TI201 imaging done.
I'm concerned about the radiation exposure from the catheterization because I am only 25 years old.
Thank you, Doctor.

jay, 20~29 year old female. Ask Date: 2020/06/11

Dr. Wu Xueming reply Cardiology

According to your report, there is indeed a condition of hypoxia in the myocardium.
Medication treatment can be initiated; if symptoms do not improve, consideration should be given to undergoing a cardiac catheterization.

Reply Date: 2020/06/11

More Info

Based on the information provided, it appears that you are experiencing symptoms consistent with myocardial ischemia, as indicated by the results of your myocardial perfusion imaging. The findings suggest significant perfusion defects in the anterior, inferior, and inferoseptal walls of the left ventricle, which are indicative of compromised blood flow to these areas of the heart muscle. Given that your summed stress score (SSS) is above 13, this is classified as high risk, and it is understandable that you are concerned about the next steps in your management.

Should You Consider Cardiac Catheterization?
Cardiac catheterization is often recommended when there is a high suspicion of significant coronary artery disease (CAD) or when non-invasive tests indicate severe ischemia, as in your case. The purpose of this procedure is to directly visualize the coronary arteries and assess for blockages or narrowing that could be contributing to your symptoms and the observed ischemia.
In your situation, the following factors support the consideration of cardiac catheterization:
1. Severe Ischemia Indicated by Imaging: The myocardial perfusion scan shows severe reductions in uptake in multiple regions of the heart, which suggests that there may be significant blockages in the coronary arteries. This is particularly concerning given your age and the potential for underlying cardiovascular issues.

2. Symptoms of Dyspnea: Your experience of shortness of breath, especially when sitting, could be related to cardiac issues, and it is important to rule out any significant coronary artery blockages that could be causing these symptoms.

3. Previous Cardiac History: You mentioned a history of mitral valve prolapse and tricuspid regurgitation. While these conditions can contribute to symptoms, they do not typically cause myocardial ischemia directly. However, they can complicate the clinical picture and may require further evaluation.

4. Normal Echocardiogram: While your echocardiogram showed normal blood flow, the presence of ischemia on the perfusion study suggests that there may be transient issues with blood flow that are not always captured on echocardiography, especially during stress.

Considerations Regarding Radiation Exposure
Your concern about radiation exposure from cardiac catheterization is valid, especially at a young age. However, it is important to weigh the risks of radiation against the potential benefits of identifying and treating any significant coronary artery disease. The radiation dose from a cardiac catheterization is generally higher than that from a myocardial perfusion scan, but the procedure can provide critical information that may help prevent future cardiac events.

Next Steps
1. Discussion with Your Cardiologist: It is crucial to have a thorough discussion with your cardiologist regarding the risks and benefits of proceeding with cardiac catheterization. They can provide insights based on your specific clinical situation and help you understand the rationale behind their recommendations.

2. Monitoring Symptoms: Continue to monitor your symptoms closely. If you experience worsening shortness of breath, chest pain, or any other concerning symptoms, seek medical attention promptly.

3. Lifestyle Modifications: While you mentioned not having hypertension, diabetes, or hyperlipidemia, maintaining a heart-healthy lifestyle is essential. This includes a balanced diet, regular exercise, and avoiding smoking or excessive caffeine, which may exacerbate your symptoms.

4. Follow-Up Testing: If catheterization is not immediately pursued, regular follow-up with your healthcare provider is important to monitor your condition and reassess the need for further testing based on your symptoms and any changes in your clinical status.

In conclusion, given the severity of your myocardial ischemia and the associated symptoms, cardiac catheterization is a reasonable next step to further evaluate your coronary arteries. It is essential to have an open dialogue with your cardiologist to make an informed decision that aligns with your health needs and concerns.

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