What is the next best step for a 72-year-old female with a recent positive (Positive) myocardial perfusion scan (Sestamibi study) showing a small zone of infarct and low to moderate risk for cardiac events, with a left ventricular ejection fraction of 72%, transient ischemic dilatation, and coronary artery calcification in the circumflex artery?

From the Guidelines

The next best step for this 72-year-old female with a recent pharmacologic nuclear stress test (PNST) is to initiate medical therapy with aspirin 81mg daily and a moderate-intensity statin, as well as optimization of cardiovascular risk factors, given the low to moderate risk for cardiac events indicated by the scan results. The Sestamibi study demonstrates a small zone of reduced radiotracer uptake in the inferior lateral segments, consistent with a small prior infarct, but no reversible ischemia is seen, which is a crucial factor in determining the management strategy 1. The preserved left ventricular ejection fraction of 72%, normal myocardial thickening and wall motion on gated SPECT imaging, and borderline transient ischemic dilation ratio of 1.10 are all reassuring findings that support a conservative approach.

Key points to consider in the management of this patient include:

• The presence of coronary artery calcification in the circumflex artery, which indicates atherosclerotic disease but does not necessarily mandate invasive intervention at this time.
• The importance of comprehensive risk factor modification, including blood pressure control, diabetes management if applicable, smoking cessation if needed, and lifestyle modifications such as diet and exercise, to reduce the risk of future cardiac events.
• Close clinical follow-up in 3-6 months to reassess symptoms and treatment efficacy, with consideration of coronary angiography if the patient develops worsening symptoms despite optimal medical therapy.

Given the patient's current presentation and the findings from the PNST, aggressive medical management rather than immediate invasive coronary angiography is the most appropriate next step, as it aligns with guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) who are classified as being at low risk after stress testing 1. This approach prioritizes the reduction of morbidity, mortality, and improvement of quality of life by managing the patient's cardiovascular risk factors and symptoms without immediately resorting to more invasive procedures.

From the Research

Patient Profile and Test Results

• The patient is a 72-year-old female with a recent history of PNST (peripheral nerve stimulation test).
• A Sestamibi study showed homogeneous tracer distribution except in the inferior lateral segments, which had a small zone of reduced radiotracer uptake at rest and stress, consistent with a small zone of infarct.
• No reversible ischemia was seen in non-attenuated corrected images.
• Gated SPECT imaging revealed normal myocardial thickening and wall motion.
• The left ventricular ejection fraction was calculated to be 72%.
• Transient Ischemic Dilatation of 1.10 was observed.
• Coronary artery calcification was seen in the circumflex artery.
• The scan indicates a low to moderate risk for cardiac events.

Recommended Next Steps

• Based on the patient's profile and test results, the next best step would be to consider a combination therapy with aspirin, a statin, and a beta-blocker, as well as an ACE inhibitor or angiotensin receptor blocker, as supported by studies 2, 3, 4, 5.
• This combination therapy has been shown to reduce the risk of vascular events and mortality in patients with coronary artery disease.
• The use of a polypill approach, which combines these medications into a single pill, may also be considered to improve drug compliance and reduce mortality 3, 5.
• The patient's low to moderate risk for cardiac events and the presence of coronary artery calcification in the circumflex artery suggest the need for aggressive management of cardiovascular risk factors.
• The patient's normal myocardial thickening and wall motion, as well as the absence of reversible ischemia, suggest that the patient may not require immediate revascularization procedures.