From the Guidelines
For a small fixed perfusion defect in the anterior wall with mild severity ischemia on NM SPECT stress test, but with normal ejection fraction and no wall motion abnormality, I recommend a dual approach of medical therapy and risk factor modification. This approach is based on the latest guidelines and evidence, including the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease 1. The patient's condition, with a small fixed perfusion defect and mild ischemia, suggests a low to intermediate risk of cardiac events, and medical therapy is a reasonable initial approach. The following medications are recommended:
- Daily aspirin 81mg to reduce the risk of myocardial infarction
- A moderate-intensity statin such as atorvastatin 20mg daily to lower LDL cholesterol and reduce the risk of cardiovascular events
- Consider a beta-blocker like metoprolol 25mg twice daily if there are no contraindications, to reduce myocardial oxygen demand and prevent ischemia Lifestyle modifications are also essential, including:
- A heart-healthy diet to reduce cardiovascular risk factors
- Regular exercise, such as 30 minutes of moderate activity 5 days per week, to improve cardiovascular health
- Smoking cessation if applicable, to reduce the risk of cardiovascular events
- Blood pressure control to reduce the risk of cardiovascular events For follow-up, schedule a cardiology consultation within 1-2 months to evaluate symptom response and medication tolerance. The use of SPECT MPI, as described in the 2017 ACR Appropriateness Criteria for chronic chest pain-high probability of coronary artery disease, is a useful tool for evaluating patients with suspected coronary artery disease 1. However, in this case, the patient has already undergone NM SPECT stress test, and the results indicate a small fixed perfusion defect with mild ischemia. Therefore, the focus should be on medical therapy and risk factor modification to prevent progression of coronary artery disease and reduce the risk of future cardiac events. If symptoms worsen or new symptoms develop before the follow-up appointment, immediate medical attention should be sought.
From the Research
Recommended Treatment
- The patient's NM SPECT stress test results show a small fixed perfusion defect in the anterior wall with mild severity ischemia, normal ejection fraction, and no wall motion abnormality.
- According to the study 2, a combination therapy with aspirin, an ACE inhibitor, and a statin can reduce 1-year mortality in patients after acute myocardial infarction.
- The study 3 also supports the use of beta-blockers and ACE inhibitors in combination for patients with cardiovascular diseases, as it provides effective blood pressure lowering and improved cardiovascular outcomes.
- However, the study 4 suggests that the combination of statin with ACEI may be the preferred treatment strategy to reduce mortality rates in STEMI patients after successful PCI with DES, rather than statin with ARB.
Follow-up
- The study 5 found that men with a positive stress test and normal myocardial perfusion gated SPECT have a more adverse prognosis than women, with a higher incidence of hard events and coronary revascularization.
- The study 6 recommends the use of stress myocardial perfusion tomography incorporating stress-only imaging for evaluating patients with low-to-intermediate-risk acute chest pain, as it is comparable to cardiac CT angiography in terms of time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure.
- Regular follow-up and monitoring of the patient's condition, including stress tests and myocardial perfusion imaging, may be necessary to assess the effectiveness of the treatment and adjust the treatment plan as needed 6.