The role of stress echocardiography and competing technologies for the diagnostic and prognostic assessment of coronary artery disease.

Coronary artery disease remains the leading cause of death in adults in the United States. Non-invasive cardiac imaging is now central to the diagnosis and management of patients with known or suspected coronary disease. The generally accepted indications for stress testing include confirming a diagnosis of coronary disease, assessing prognosis, preoperative risk stratification, and evaluation of medical therapy. Stress echocardiography and single photon computed tomography are well-established non-invasive techniques for all the previously mentioned indications. These modalities provide a relatively high sensitivity and specificity along with an incremental value over clinical risk factors. Cardiac magnetic resonance imaging (CMRI) and multislice computed tomography are new imaging tools in the evaluation of patients with coronary disease. CMRI offers a comprehensive cardiac evaluation which includes wall motion analysis, myocardial tissue morphology, rest and stress first pass myocardial perfusion as well as systolic ventricular function. It is also considered a first line technique for the diagnosis of certain structural heart disease and chamber volume quantification. Cardiac computed tomography allows non-invasive anatomic imaging of the coronary tree. It has a high clinical utility especially in select intermediate risk patient population. Available tests all have advantages and drawbacks and none can be considered suitable for all patients. The choice of the imaging method should be tailored to each person based on the clinical judgment of the a priori risk of cardiac event, clinical history, and risk factors profile.

Spontaneous coronary artery dissection presenting as acute myocardial infarction.

Spontaneous coronary artery dissection is a rare entity being increasingly diagnosed as a cause of acute myocardial infarction, especially in cases of low cardiac risk female patients. This is one such case report of a black female patient, who suffered an acute anterior wall myocardial infarction due to an idiopathic spontaneous coronary artery dissection of the left anterior descending artery. She was treated with a thrombolytic agent in the acute phase, uneventfully. An urgent coronary angiogram demonstrated an intimal tear with a dissection of the left anterior descending artery. She survived the acute event and her subsequent hospital course was uncomplicated. Hence she was treated medically for her ischemic event and left ventricular systolic dysfunction with a favorable outcome. This case is yet another report of a survivor treated with a thrombolytic agent for the acute myocardial infarction due to spontaneous coronary artery dissection.