Description
In May 2012, a 73-year-old man presented with effort dyspnoea and chest discomfort, negative exercise test for ST depression and ventricular ectopy after exercise. He had a history of Sjögren's syndrome, diabetes, dyslipidemia, hypertension, chronic obstructive pulmonary disease and was under methotrexate treatment for rheumatoid arthritis. Such diseases imply a severe dysfunctional burden, tend to develop accelerated atherosclerosis, endothelial dysfunction and ischaemic heart disease (IHD).1 2 A functional assessment was thus provided with an exercise/rest technetium-99 m tetrofosmin-gated single-photon emission cardiac tomography (G-SPECT). This test did not show perfusion defects; left ventricular function was normal (figure 1). At peak exercise, there was lack of ST-depression, but episodes of ventricular triplets were detected after exercise (figure 2). A cardiac tomography (CT) scan detected a severe stenosis in the middle portion of the left anterior descending (LAD) coronary artery (figure 3). An invasive coronary angiography revealed 90% stenosis of the LAD; therefore, a stent was implanted. Ventricular ectopy after exercise is associated with reactivation of parasympathetic activity and an increased risk of death.3 In the presence of a subocclusive LAD stenosis, the patient's exercise SPECT results should be thus considered as false negative. Occult exercise-induced ischaemia and a reperfusion mechanism for postexercise ventricular ectopy cannot be ruled out. Reperfusion re-establishes slow conduction through depressed regions, permitting re-entrant pathways to form again, resulting in the re-emergence of ventricular arrhythmias.4 Cardiac CT may provide early-stage screening for occult IHD in patients with multiple risk factors for IHD and defective anginal warning system.
Figure 1.
Exercise-gated /rest-gated single-photon emission cardiac tomography shows lack of significant perfusion defects and a normal left ventricular function.
Figure 2.
A run of ventricular triplets and an isolated ventricular ectopy during the exercise test recovery period. Heart rate (HR); beats per minute (bpm) and systolic blood pressure (SBP).
Figure 3.
Volume-rendered cardiac CT images indicate a severe stenosis in the middle portion of the anterior descending (LAD) artery. Aorta(Ao), pulmonary trunk (PT) and left circumflex artery (Cx).
Learning points.
Rheumatoid arthritis and other rheumatic diseases significantly increase the risk of atherosclerosis.
Diabetes, rheumatoid arthritis and Sjögren's syndrome may lead to uncommon presentations of ischaemic heart disease.
If pretest probability is high, negative test results should not stop investigations.
Ventricular arrhythmias may be a sign of cardiac hypoperfusion even in a negative test.
Footnotes
Competing interests: None.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
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