Introduction: To investigate the presence of significant coronary artery disease (sCAD), the clinician may resort to the use of anatomical or functional tests. When multiple factors contribute to the genesis of ischemia, a single test may not be enough, and an integrated approach is essential.
Clinical case: 74-year-old man, athlete, has been complaining dyspnoea after intense exertion for 3 months. Rest ECG and echocardiogram were unremarkable. A cardiopulmonary exercise test (CPET) showed excellent functional capacity (peakVO2 24 ml/Kg/min, 113% of predicted value) without signs of ischemia; however, the test was stopped early due to high blood pressure (250/120 mmHg) and therefore submaximal (peak RQ 0.95). Antihypertensive therapy was set. A coronary CT showed sCAD. The coronary angiography revealed significant stenosis of the middle circumflex artery and significant stenosis of the distal right coronary artery; both lesions were treated with angioplasty and stent implantation.
Due to symptoms persistence, we performed a new CPET. The test was maximal (peak RQ 1.13), confirming an even better functional capacity, but highlighting the presence of inducible ischemia (O2-pulse downsloping and VO2/W flattening). A new coronarography showed good angiographic result. The results prompted our team to revise the anatomic tests, leading to the finding of intramyocardial course of anterior interventricular artery. Verapamil 80mg t.d.s. was set.
Before discharge, a CPET was repeated: the test was maximal (RQ 1.1) and showed attenuation of signs of ischemia at high load. Following discharge, the patient reported well-being during regular follow-up.
Conclusions: our case highlights how the integration of anatomic and functional diagnostic tests (performed during a proper physical exercise), plays a key role in the management of suspected myocardial ischemia. The clinical case also shows how CPET is a valuable tool for the detection of myocardial ischemia only if performed reaching the maximality criteria.
