Nuclear/Cath

Correlation
Conference
David M. Whitaker, MD
University of South Florida
Department of Cardiology
 Case #1
55 yo man seen in clinic for chest pain
Left sided
Sharp
Both at rest and with activity – 5/10
severity
Has dyspnea with mild-mod exeretion
No alleviating factors/meds
 Case #1
PMH
Diabetes – poorly controlled
HTN
Hyperlipidemia
Seizures
Depression

Social
Divorced, 5 kids, lives with his mother.
On disability for seizures. Prior 6 pack
per day – quit one year ago. Non-smoker.
Cocaine in early 1980’s, none since
 Case #1
Medications
Aspirin 325mg
Simvastatin 40mg
HCTZ 25mg
Metoprolol 50mg bid
Insulin, metformin, gabapentin, etodolac
carbamazapine
 Case # 1
Examination
BP 148/78, HR 87, T 99.1, RR 18, BMI
37
Obese man in no distress
Normal S1S2, no m/r/g, +/- jvd
Soft bibasilar crackles
Soft obese abdomen
1+ pitting leg edema with palpable
pulses
 Case #1
LABS
A1c – 11.3
Hgb 14
Na 136, co2 34, bun 20, creat 1.2, gluc
212
Alk phos 148, normal ast/alt
Chol 208, tri 101, hdl 60, ldl 128
EKG
 Case #1
Adenosine Stress Test
 Case #1
Adenosine Stress Test
Mild to moderate potential ischemia of
the lateral and inferolateral walls apex 
base
EF 46-48%
 Case #1
Heart Cath
 Case #1
Heart Cath
Right Dominant
Left Main – okay
LAD – 99% discrete lesion
Circ – mid 100%
RCA – proximal 35%, distal Lum.Irreg
30%
Collateral – Ramus  Marginal
EF – 55%
LV 152/3, 18
 Case #1
Cath Conference  try PCI

PCI to LAD (Xience) 2.75 x 18mm

PCI to Circ (Xience) 2.75 x 28mm

 Case #2
61 yo man with no prior cardiac history
referred from anesthesia for CRA due to
abnormal EKG

Planned to undergo FESS with brain lab

& polypectomy under general
anesthesia

Denied chest pain, orthopnea, PND

etc…
 Case #2
PMH
Recurrent DLBC lymphoma s/p chemos
COPD/Asthma
Hyperlipidemia

Social
Married, works as a security officer
Long time smoker, occas alcohol
 Case #2
Medications
Simvastatin 20mg
Paroxetine
Oxycodone
Albuterol, mometasone, formoterol,
albuterol
xanax
 Case #2
Examination
111/80, 74, 98.1, 16, 207 lbs
No jvd, normal carotids
Clear lungs
Normal S1S2, pmi
No edema, normal pulses
 Case #2
Labs
Na 141, co2 30, bun 14, creat 1.0, gluc
185
Wbc 9, hgb 14.6, plt 225
Chol 172, tri 175, hdl 62, ldl 75
EKG
 Case #2
AST recommended  Dobutamine

Echo
 Case #2
Dobutamine Nuclear
Markedly dilated LV
Inferior wall ischemia of varying severity
from apex  base
EF 30% with global hypo
 Case #2
Echo
EF 40%
Severe hypo basal inferoseptal, basal
inferior
Remaining walls mod hypo
Biatrial dilatation
Mild MR, trace-mild TR
RVSP 50 mmHg
 Case #2
Cath
 Case #2
Cath
Normal coronaries
Normal systemic pressure
LVEDP 26
PCWP 25
PAS/PAD 54/21
RA 8
CO 4.8, CI 2.28 (both by Fick)
EF 30% with global hypo
 Case #3
62 yo man seen for CRA for inguinal
hernia repair as EKG abnormal

No known prior CAD documented by

cath per his memory

Sleeps on 2 pillows, no chest pain

COPD at baseline with irregular use of

inhaler meds
 Case #3
PMH
CVA
HTN
Hyperlipidemia
GERD
BPH

Social
Single, disabled
0.5 – 1 ppd long time, occas alcohol
 Case #3
Meds
Simvastatin 20mg
Lisinopril 5mg
Metoprolol 12.5mg bid
Aspirin 81mg
Combivent, formoterol
baclofen
 Case #3
• Examination
– 125/72, 60, 99.2, 16, 155 lbs
No jvd, no bruits
Regular S1S2, +S4
– Lungs are clear
Faint left femoral
Large right inguinal hernia
– Pedal pulses palpable, no edema
EKG
 Case #3
• AST
 Case #3
• AST
Moderately severe ischemia in apex and
apical 1/3rd of anterior, anteroseptal,
inferoseptal walls
– Post-stress stunning evident
TID present
EF 54-60%
 Case #3
• Echo
– EF 60%
Normal wall motion, normal LV thickness
Trace-mild MR
 Case #3
• Cath
 Case #3
• Cath
– Severely calcified LAD with ostial 80%,
proximal 95%, mid 100%
Distal LAD fills via collateral
Mild circumflex disease
– Diffuse 70% mid and distal RCA
80% ostial PDA
 Case #4
• 70 yo man with known CAD/PCI in
January
• Admitted with chest pain/tightness
starts on the right lower chest and
radiates to the left chest and abdomen.
Is associated with SOB. Lasts for 15-30
minutes

Came to hospital when realized his HR

also was elevated
 Case #4
• PMH
– CAD s/p PCI in January
HTN
PVD
– Hyperlipidemia
DM2
Sickle Trait
• Social
Married, healthy son, retired
20 pack yr smoker, quit 30 yrs ago, no
etoh
 Case #4
• Meds
– Aspirin
Plavix
Lisinopril 20mg
– Isosorbide mononitrate 30mg
Coreg 25mg bid
Lasix 40mg
– Insulin 70/30
Simvastatin 80mg
 Case #4
• Examination
– 117/73, 81, 97.9, 18, 243 lbs
No jvd, no bruits
Irreg irreg, normal S1S2
– Clear lungs
Obese but normal abd
+3 pitting leg edema
– Normal distal pulses bilaterally
 Case #4
• Labs
– Wbc 10
Hgb 15
Plt 233
– Na 137, co2 27, bun 35, creat 1.8, gluc
153
Bnp 461, trop 1.197, ckmb 12.38
Chol 149, tri 101, hdl 42, ldl 87
EKG
 Case #4
• AST
 Case #4
• AST
Potential ischemia in the apex and apical
1/3rd of the lateral wall
EF 59-61%
Slightly greater potential ischemia than
study in March
 Case #4
• Cath
 Case #4
• Cath
– Left main okay
LAD – patent prior mid stent
Circ – minimal luminal irreg
RCA – minimal luminal irreg
EF 60%, normal wall motion