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A 47 year old man, without a history of hypertension, was admitted for chest pain. Stress and rest 201-thallium perfusion scintigraphy was performed, using dipyridamole and bicycle exercise (50 W workload). The stress image (panel A) revealed diminished tracer uptake in the inferior wall of the left ventricle (LV) and the inferoseptal wall of the right ventricle (RV). On the rest image (panel B), acquired four hours later, almost complete redistribution was demonstrated which indicates both LV and RV ischaemia. In addition, the stress ECG (panel C) showed ST segment depression in the inferior leads and ST segment elevation in leads aVR and V1, reflecting both LV and RV ischaemia. Compared to the rest ECG (panel D) P wave amplitude increased during stress, which may have been caused by increased atrial pressure as a result of transient end diastolic pressure elevation caused by stress induced myocardial ischaemia. Subsequent coronary angiography (panels E and F, right anterior oblique and left anterior oblique projection, respectively) demonstrated significant stenosis of the right coronary artery (RCA) proximal to the take off of the right ventricular branch (RVB) which shows an ostial and distal stenosis (see arrows). Coronary angiography showed no stenosis in the left coronary artery.
This case demonstrates that stress/rest 201 thallium perfusion scintigraphy and stress ECG enables the detection of RV ischaemia caused by significant RCA stenosis.