Case Compendium

Case Compendium

The Refer Wisely Case Compendium is a series of common clinical scenarios that referring physicians face in their practice when deciding on appropriate diagnostic testing in patients with known or suspected coronary artery disease. Each case is presented by a nuclear cardiologist and an internal medicine specialist to ensure the content is appropriate to helping referring physicians choose the right test for their patients.
Case discussions focus on patient-centered evaluation:
  • What questions need to be answered?  
  • What tests will provide the answers?  
  • What is a proper treatment plan based on test results? 
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Presenters, Ronald G. Schwartz, MD and Andria Medina, MD, discuss a 57-year old male with atypical chest pain, coronary risk factors, and a non-diagnostic ECG. The patient describes atypical postprandial chest pain with walking. The case examines the role of functional testing with SPECT myocardial perfusion imaging compared to anatomical testing to enhance the clinical assessment of the exercise ECG and its role in appropriate patient management. Results from the PROMISE trial are discussed in the context of management of this patient, and the evidence of downstream testing and costs of SPECT MPI vs anatomic coronary imaging are reviewed. Evidence for the appropriate selection of patients for revascularization with SPECT MPI are discussed.

Presenters, Larry Phillips, MD, and Gretchen Diemer, MD, discuss a 63-year old male referred for a myocardial perfusion study after an abnormal screening test (coronary artery calcium score of >400) but he has no symptoms of underlying disease. They discuss the issues in choosing the next step in management and underline the importance of risk assessment, ischemic burden, and knowledge of appropriate use criteria. 

Presenters Larry Phillips, MD and Gretchen Diemer, MD, discuss an asymptomatic 59-year old male with history of HIV, CABG, PCI (> 5 years) undergoing cardiac risk assessment. On a routine follow-up visit the patient has no symptoms of chest pain or shortness of breath, but has a history of peripheral vascular disease. Should the patient be referred for an exercise stress myocardial perfusion imaging study?

Presenters, David Wolinsky, MD and Gretchen Diemer, MD discuss the value of cardiac imaging in an asymptomatic patient who underwent a series of cardiac imaging tests and coronary angiography. The case points out that clinical judgment is paramount in determining whether further evaluation of a patient is indicated. Appropriate Use Criteria help confirm that the choice of test is reasonable and beneficial in the patient’s management.
Presenters David Winchester, MD and Gretchen Diemer, MD, discuss a patient who presents at follow-up 2-years post PCI with modest chest discomfort following walking up one flight of stairs. Appropriate steps in evaluating this patient with stable disease 2 years following the PCI and a comparison of the various appropriate diagnostic tests are presented.

Presenters Raymond Russell, MD and Andria Medina, MD, discuss the importance of evaluating cardiac risk factors in choosing the appropriate diagnostic test to evaluate this patient prior to knee replacement surgery.  Appropriate use criteria for imaging and also for perioperative management are compared.

Presenters David Wolinsky, MD and Andria Medina, MD, discuss a patient who experienced shortness of breath and weakness after walking up 2 flights of stairs.  In the ER, his examination was normal.  The case details the importance of clinical history and appropriate testing to diagnosis and establish the long-term cardiac risk for this patient.

Presenters Ronald Schwartz, MD and Andria Medina, MD, discuss a patient is admitted to the hospital with chest pain.  His ECG was interpretable with no findings of ischemia, cardiac biomarkers were normal but he has several cardiac risk factors. Appropriate next steps and diagnostic testing in the timely management of this patient are reviewed.

Presenters Rami Doukky, MD and Gretchen Diemer, MD discuss a 58-year old male with stable angina and moderate activity of daily living. Choosing the appropriate next step in the management of his coronary artery disease can be challenging.

Presenters David Wolinsky, MD and Gretchen Diemer, MD, discuss the importance of risk factors in determining the short-term risk, short-term treatment and the role of additional diagnostic testing in establishing long-term management for this intermediate risk female with chest pain

Presenters Ronald Schwartz, MD and Andria Medina, MD discuss a 73-year old male with atypical angina and fatigue.  His history includes chronic kidney disease and osteoarthritis of the knee which can complicate the choice of testing to diagnose potential disease. 

Presenters Raymond Russell, MD and Andria Medina, MD, discuss a patient who presents with new LBBB with decreased exercise capacity but no significant chest pain. A decision on appropriate testing in this patient, such as interpreting an exercise stress test, can be difficult.

Presenters David Wolinsky, MD and Andria Medina, MD, explore the “determinants of need” for pre-operative testing, and the appropriate cardiac evaluation prior to surgery in a patient with peripheral vascular disease and potentially significant coronary artery disease.

Presenters David Winchester, MD and Gretchen Diemer, MD discuss the question of whether this 62-year old female should undergo a nuclear stress test or some other imaging modality to screen for occult coronary artery disease in a high risk patient .