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Myocardial perfusion imaging detected progressive myocardial ischemia in a chronic kidney disease patient with normal coronary angiography

Session Clinical Case Poster session II

Speaker Assistant Professor Chrissa Sioka

Congress : ICNC, Nuclear Cardiology & Cardiac CT 2019

  • Topic : imaging
  • Sub-topic : Single Photon Emission Computed Tomography (SPECT)
  • Session type : Clinical Case Posters
  • FP Number : 180

Authors : C Sioka (Ioannina,GR), K Papadimitropoulos (Ioannina,GR), T Al Boucharali (Ioannina,GR), K Sakelariou (Ioannina,GR), E Gkika (Ioannina,GR), K Pappas (Ioannina,GR), L Lakkas (Ioannina,GR), L Michalis (Ioannina,GR), P Pavlakou (Ioannina,GR), O Balafa (Ioannina,GR), V Koutlas (Ioannina,GR), E Dounousi (Ioannina,GR), A Fotopoulos (Ioannina,GR)

Authors:
C Sioka1 , K Papadimitropoulos1 , T Al Boucharali1 , K Sakelariou1 , E Gkika1 , K Pappas2 , L Lakkas2 , L Michalis2 , P Pavlakou3 , O Balafa3 , V Koutlas3 , E Dounousi3 , A Fotopoulos1 , 1University Hospital of Ioannina, Department of Nuclear Medicine - Ioannina - Greece , 2University Hospital of Ioannina, Department of Cardiology - Ioannina - Greece , 3University Hospital of Ioannina, Department of Nephrology - Ioannina - Greece ,

On behalf: None

Citation:

Introduction and patient description: Cardiovascular complications, mostly due to coronary artery disease (CAD), are common in patients with chronic kidney disease (CKD) and account for almost 50% of deaths. This is a case of a 66-year-old patient with CKD diagnosed with end-stage chronic kidney disease of unknown etiology in 1993. He stayed on intermittent hemodialysis until 1997, when he received a renal transplant from his 72 years old mother. In 2016, the patient lost the transplanted kidney and was restarted on hemodialysis.

Identification of the problem, procedures, techniques and patient management: In 2013, the CKD stage four patient due to chronic allograft dysfunction had his first MPI SPECT scan. This test revealed reversible defects indicating mild ischemia of the inferior/inferolateral cardiac wall and part of the myocardial apex. While the patient being asymptomatic, successive MPI SPECT performed in years 2013, 2014, 2016 and 2017 (Fig A, a: 2013; b: 2014; c: 2016; d: 2017), demonstrated progressively established ischemia partially reversible at rest. Due to deteriorating MPI SPECT images, a coronary angiogram was performed in 2017, which failed to reveal any hemodynamically significant coronary stenoses (Fig B). Consistent with the MPI SPECT results was obtained by echocardiography which demonstrated a deteriorating hypokinesia of the left ventricular wall in the yearly examinations.

Questions, problems or possible differential diagnosis: Both two imaging methods (MPI and U/S), verified the existence of myocardial ischemia in this patient ruling out an artifactual phenomenon. This raised the question why this patient did not have CAD.  Was it due to a reversible vasoconstrictive mechanism? Should such patients be subjected to MPI screening tests? And if so, could these patients have any preventive therapeutic interventions? The images emphasize the value of MPI to detect myocardial ischemia possibly due to irregular vasoconstrictor/vasodilatory coronary capability. In fact, scientific evidence suggests that renalase, a flavin adenine dinucleotide-dependent amine oxidase is increased during CKD, metabolizes catecholamines and may increase the levels of circulating endothelin-1, a potent vasoconstrictor. Thus, episodes of reversible coronary vasoconstriction may result in myocardial ischemia without obvious coronary stenoses.

Conclusions and implications for clinical practice: Patients with CKD are in high risk for myocardial ischemia and should be screened routinely with several imaging methods, especially with MPI, an imaging that can provide crucial information about the cellular myocardial status. Irregular vasoconstrictor/vasodilatory coronary capability can be a risk factor for ischemia in this group of patients, independent of the existence or not of CAD.

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