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A patient with angina at night
Clinical case
Authors:
Frank A. Flachskampf - Uppsala Universitet, Akademiska Sjukhuset, Uppsala, Sweden
Roger R.J.C. Hall - University of East Anglia, Norwich, United Kingdom
Educational Resource:
ESC Core Curriculum Chapter 3 (Non-invasive imaging), Chapter 9 (Chronic Ischaemic Heart Disease)
Introduction:
A 66 year old male patient was referred for evaluation. He had suffered from several nightly anginal attacks but had been symptom-free for the last days.His resting ECG is reproduced in Fig.1. A bicycle exercise ECG test showed no further abnormalities and did not elicit anginal symptoms. He was a former smoker and had hypertension, hypercholesterolemia, and an untreated, subclinical type 2 diabetes. The patient had recently undergone computed tomography with the result of an elevated Agatston calcification score of 172 (between 50 th and 75 th percentile of age related average).
Conclusion
The case illustrates the functional benefit of revascularization of the posterolateral branch of the circumflex artery in this case of a patient with nightly angina. The findings indicate retrospectively that there was viable, but non-contracting (hibernating) myocardium in the perfusion territory of the posterolateral branch, which recovered contractile function after revascularization. Whether this treatment improves overall prognosis, is still a matter of debate. However, there are meta-analytic data suggesting a clear survival benefit of revascularization in the presence of viable, non-contracting (hibernating) myocardium [4], while the recent STICH trial did not show a clear benefit [5] .
References
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[4] Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 2002;39:1151-8
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