• Images in cardiology

A 64 year old ex-smoker with a past history of hypertension presented to the chest pain fast track clinic with a one month history of increasing breathlessness on exertion. He underwent treadmill exercise testing, and managed only 59 seconds of the Bruce protocol before developing breathlessness, ST segment elevation in leads II, III, avF, and then non-sustained ventricular tachycardia. In view of the severity of his symptoms and the changes on the exercise ECG, in-patient cardiac catheterisation was performed. This showed a 99% stenosis of the dominant right coronary artery (left hand panel). Left ventricular angiogram demonstrated akinesia of the inferoapical region (video sequence 1). The right coronary artery lesion underwent angioplasty and a 3.5 × 13 mm Coroflex stent was deployed with an excellent final result (right hand panel). Immediately following stent insertion, a further left ventricular angiogram was performed, demonstrating complete resolution of the inferoapical akinesia (video sequence 2). Following angioplasty the patient's symptom of exertional breathlessness has resolved.

These images show that critical ischaemia can lead to significant, but completely and immediately reversible, stunning of the myocardium. This is likely to be the pathological basis for the “anginal equivalent” of breathlessness, rather than chest pain, on exertion