Case 14
12-Lead ECG
The baseline ECG demonstrates normal sinus rhythm, left-axis deviation, and LBBB.
Following are options for identification of cardiomyopathy due to CAD (ischemic cardiomyopathy):
Coronary CTA of Left Anterior Descending
The LAD demonstrated diffuse mixed (calcified and noncalcified) nonobstructive plaque.
Coronary CTA of Right Coronary Artery
The proximal and mid-RCA demonstrated diffuse calcified (nonobstructive) plaque.
Clinical Questions
1. Does he have ischemic cardiomyopathy? Probably not. His severe left ventricular systolic dysfunction is out of proportion to the mild (nonobstructive) CAD identified by CTA. The constellation of findings (LBBB, severe global left ventricular hypokinesis, nonobstructive CAD) are most consistent with nonischemic cardiomyopathy.
2. Is he likely to benefit from coronary revascularization? No. There was no inducible ischemia reported on SPECT MPI (and he has no evidence of obstructive CAD by CTA).
3. Would he benefit from aggressive risk-factor modification? Yes. There is diffuse coronary atherosclerosis confirmed by CTA. This information would not have been available if a physiologic test (e.g., dobutamine echocardiography or PET MPI) rather than an anatomic test (CTA) had been performed to evaluate for ischemic cardiomyopathy.
| MPI | CTA |
|---|---|
| Physiology | Anatomy |
| Myocardial perfusion | Coronary plaque |
| Short-term (2-year) risk | Long-term (10-year) risk |
| Revascularization? | Secondary Prevention? |
