Excerpt

A 77-year-old man developed dyspnea on exertion. Ten years previously he had similar symptoms. There was 4-chamber cardiac enlargement with normal ventricular function on cardiac magnetic resonance imaging (CMR). Exercise treadmill testing revealed no ischemia on the ECG. He declined medical therapy and took over the counter supplements. His symptoms resolved, but there was a recent decline in left ventricular ejection fraction (LVEF) to 35-45%. A regadeonoson myocardial perfusion scan was obtained to evaluate the possibility of myocardial ischemia. These images revealed perfusion abnormalities in the anterior wall, apex, and lateral wall that were reversible on resting images, consistent with ischemia (Figure 1). There was a fixed perfusion defect in the inferior wall that persisted in spite of attenuation correction. The calculated LVEF was 38%. Despite the strikingly abnormal nuclear perfusion images, coronary angiography revealed only minimal coronary atherosclerosis (Figure 2).

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