Dipyridamole nuclear myocardial perfusion imaging is a safe and useful modality to assess for myocardial ischemia. It is the modality of choice for cardiac risk stratification in patients unable to exercise. Intravenous dipyridamole causes coronary vasodilation and may yield heterogeneity of coronary blood flow in significant coronary artery disease. Ischemic electrocardiographic changes following pharmacologic stress testing are less likely compared to exercise stress tests. Ischemia more likely presents in the form of ST depression, with ST-elevation being exceedingly rare. We present a case of a 73-year-old patient who developed ST-elevation myocardial infarction following pharmacologic stress testing

Al Hennawi, Hussam

Atam, Sarin

Khan, Shayan Iqbal

Lakhani, Sunita

Nair, Abhinav

Rigotti, Joseph

Sadiq, Usama

Jefferson Digital Commons

Thomas Jefferson University Jefferson Digital Commons Abington Jefferson Health Papers Abington Jefferson Health 6-27-2023 Dipyridamole-Induced Stemi: Case Report and Review of the Literature Hussam Al Hennawi Sunita Lakhani Shayan Iqbal Khan Sarin Atam Usama Sadiq See next page for additional authors Follow this and additional works at: https://jdc.jefferson.edu/abingtonfp  Part of the Cardiology Commons, and the Surgery Commons Let us know how access to this document benefits you This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Abington Jefferson Health Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Authors Hussam Al Hennawi, Sunita Lakhani, Shayan Iqbal Khan, Sarin Atam, Usama Sadiq, Joseph Rigotti, and Abhinav Nair OPEN ACC ESS1 Department of Internal Medicine, Jef-ferson Abington Hospital, Abington,PA, USA2 Department of Cardiology, Thomas Jef-ferson University Hospitals, Philadel-phia, PA, USA3 Department of Cardiology, JeffersonAbington Hospital, Abington, PA, USA*Email: hussamhen-nawi.md@gmail.comhttps://doi.org/10.21542/gcsp.2023.23Received: 12 May 2023Accepted: 20 June 2023© 2023 The Author(s), licenseeMagdi Yacoub Institute. This is anopen access article distributed un-der the terms of the Creative Com-mons Attribution license CC BY-4.0,which permits unrestricted use, dis-tribution and reproduction in anymedium, provided the original workis properly cited.Cite this article as: Al Hennawi H, Lakhani S, Khan SI, Atam S, Sadiq U, Rigotti J, Nair A.Dipyridamole-induced STEMI: case report and review of the literature, Global Cardiology Scienceand Practice 2023:23 https://doi.org/10.21542/gcsp.2023.23Images in cardiologyDipyridamole-induced STEMI: casereport and review of the literatureHussam Al Hennawi1*, Sunita Lakhani1, Shayan Iqbal Khan1, Sarin Atam1, Usama Sadiq2,Joseph Rigotti1, Abhinav Nair3ABSTRACTDipyridamole nuclear myocardial perfusion imaging is a safe and useful modality for assessingmyocardial ischemia. It is the modality of choice for cardiac risk stratification in patients whoare unable to exercise. Intravenous dipyridamole causes coronary vasodilation and mayresult in heterogeneity of coronary blood flow in significant coronary artery disease. Ischemicelectrocardiographic changes following pharmacological stress testing are less likely to occurcompared with exercise stress tests. Ischemia is more likely to be present in the form of STdepression, with ST-segment elevation being exceedingly rare. We present the case of a 73-year-old patient who developed ST-segment elevation myocardial infarction following pharmacologicstress testing.Page 2 of 8Al Hennawi et al. GCSP 2023:23INTRODUCTIONNuclear myocardial perfusion imaging (MPI) is a safe and effective modality for detectingmyocardial ischemia in patients who are unable to undergo exercise stress testing1.Dipyridamole and regadenosine are as sensitive and specific for detecting myocardialischemia as dobutamine, adenosine, and exercise stress testing1,2. In fact, whencompared with exercise myocardial perfusion testing, dipyridamole nuclear testinghas similar sensitivity (79%) and higher specificity (95% vs. 92%) for the detection ofcoronary artery disease (CAD)3.Ischemic electrocardiographic (EKG) changes during dipyridamole stress testing maymanifest as ST depression and possible angina4. ST-elevation myocardial infarction(STEMI) is an exceedingly rare complication4. Potential mechanisms of myocardial injuryinclude vasodilator-induced myocardial ischemia (coronary steal), coronary vasospasm,or plaque rupture5. We report the case of a 73-year-old male patient who developedSTEMI a few hours after dipyridamole MPI with evident severe stenosis on subsequentcoronary angiography. To the best of our knowledge, this is the first report of a delayedcomplication following dipyridamole stress testing.CASE PRESENTATIONA 73-year-old male with poorly controlled insulin-dependent diabetes mellitus,hypertension, CAD with remote coronary artery bypass graft (CABG) 30 years prior, andsevere peripheral artery disease (PAD) presented to an outside hospital for surgicalrevascularization of the right lower extremity with possible amputation.On arrival, the patient was hemodynamically stable and denied any anginalsymptoms. The patient was taking aspirin (81 mg), atorvastatin (20 mg), and insulin. Hewas being treated for cellulitis and osteomyelitis of the right leg wound prior to arrival. Anechocardiogram performed 2 weeks prior showed an ejection fraction (EF) of 45% withinferior hypokinesis. Given his medical comorbidities and no recent ischemic evaluations,he was scheduled for preoperative pharmacologic stress testing to better characterize theburden of ischemia. Pharmacological stress testing with dipyridamole was administeredintravenously at the rate of 0.56 mg/kg over 4 min. Baseline electrocardiogram (EKG)showed sinus rhythm with nonspecific T-wave changes (Figure 1).The patient experienced no symptoms during the stress test and had a normalhemodynamic response to stress testing. No significant ECG changes were observedduring the stress testing. MPI was completed uneventfully, with no perfusion defects.However, left ventricular systolic function was moderately decreased with globalhypokinesis along with anteroseptal and apical anterior akinesis (Figure 2). At thistime, he was recommended to undergo surgery without additional cardiac diagnostics/interventions at moderate to high risk.Two hours after the stress test, the patient became unresponsive and experiencedcardiac arrest. The initial rhythm was ventricular fibrillation (VF). ACLS was initiated,the patient was intubated, defibrillation was performed three times, and a return ofspontaneous rhythm was achieved in 6 min. Post-arrest EKG showed a new inferior STelevation with reciprocal ST depression in the anteroseptal leads (Figure 3). The patientwas immediately taken to the catheterization laboratory for further evaluation.Page 3 of 8Al Hennawi et al. GCSP 2023:23Figure 1. Electrocardiogram before pharmacological stress test showing sinus rhythm anteriorinfarct and non-specific T-wave abnormalities.Figure 2. Left ventricular myocardial perfusion imaging showing abnormal perfusion with nonotable left ventricular perfusion ischemia.Coronary angiography revealed severe multivessel CAD, 30% stenosis of the mid-leftmain artery, 50% stenosis of the distal right coronary artery (RCA), and 90% stenosis ofthe mid-RCA (Figure 4). Percutaneous coronary intervention (PCI) was performed withsuccessful delivery of a bare metal stent (BMS) to the mid-RCA. The patient was noted tohave recurrent myoclonic jerking during catheterization, and was deemed to have a gravePage 4 of 8Al Hennawi et al. GCSP 2023:23Figure 3. Electrocardiogram post-arrest showing wide QRS rhythm with occasional prematureventricular complexes and ST-elevation consistent with inferior infarct and reciprocal STdepression.Figure 4. Coronary angiography showing mid-left main coronary artery with an estimated 30%stenosis (A). Left anterior descending with 100% lesion. Mid-right coronary artery with 90% stenosis(culprit lesion) and distal right coronary artery with 50% stenosis (B).neurologic prognosis. He was managed in the cardiac care unit; however, in the absenceof neurological improvement, was extubated palliatively as per family wishes.DISCUSSIONDipyridamole-induced STEMI is an exceedingly rare complication reported only in afew previous scientific literature6–11. A review conducted by Lette et al. reported anincidence of 0.95 deaths and 1.76 nonfatal infarctions per 10,000 patients who receiveddipyridamole for stress testing2. The safety of dipyridamole and other vasodilatorypharmacological agents is due to the production of hyperemia with no associatedsignificant increase in myocardial oxygen demand12.Dipyridamole-induced ST-segment elevations have been observed in patients withoutcoronary lesions at the end of test procedures and after aminophylline administration,Page5of8AlHennawietal.GCSP2023:23Table 1 Overview of dipyridamole-induced ST-elevation cases from the literature.Author Reference Age andSexPost-stressEKGMechanism InitialmanagementCatheterizationreportEventualManagementAl Hennawiet al.CR 73, M Unremarkable Plaque rupture None (latepresentation)30% mid-LMCA stenosis,100% LAD stenosis.90% mid-RCA stenosis(culprit lesion)and 50% distal RCAstenosisPCI to RCAHansen et al. 6 47, M ST-segmentelevationVasodilatory-inducedcoronary stealAminophylline,SL NTGTotal occlusions ofRAD, LAD, occludeddistal circumflex and60% stenosis of thefirst oblique marginalCABGMutlu et al. 7 44, F ST-segmentelevationVasodilatory-inducedcoronary stealAminophylline,SL NTG100% RCA, 70% LAD,60% of the 2nd diagonalbranch, 70% the 3rddiagonal branch, and70% occlusion of theproximal circumflexarteryCABG(continued on next page)Page6of8AlHennawietal.GCSP2023:23Table 1 (continued)Author Reference Age andSexPost-stressEKGMechanism InitialmanagementCatheterizationreportEventualManagementSafi et al. 8 56, M ST-segmentelevationVasodilatory-inducedcoronary stealNone LCX total occlusionand proximal40–50% stenosis offirst obtuse marginalbranchMedicalmanagementKwai et al. 9 64, M ST-segmentelevationVasodilatory-inducedcoronary stealSL nifedipine,nitropaste,NTG, andmorphineOcclusion of all bypassgrafts, the native LAD,RCA, and a 90% stenosisof the LMCAStreptokinaseLi et al. 10 67, F ST depressionprogressingto ST-segmentelevationUnstableplaque ruptureAminophylline Subtotal distal RCAocclusionPCI to RCAusing a drug-coated balloonCastro et al. 11 73, F ST-segmentelevationCoronaryvasospasmSL NTG Unremarkable MedicalmanagementNotes.CR, current; SL, sublingual; NTG, nitroglycerin; ASA, aspirin; RCA, right coronary artery; LAD, left anterior descending artery; LCX, left circumflex artery; LMCA, left main coronary artery; PCI, percutaneous coronaryintervention.Page 7 of 8Al Hennawi et al. GCSP 2023:23which is attributed to the sudden termination of vasodilatory stimulation11–14. Othermechanisms, including coronary vasospasm and coronary steal phenomenon werecontributory11,15. Our patient developed cardiac arrest approximately 5 h after undergoingdipyridamole stress testing. Notably, he was asymptomatic during and shortly after thenuclear test, and there was no concern of any hemodynamic alterations that may haveexplained any impending acute coronary vessel disease (Table 1).It is unlikely that pharmacological vasodilation directly contributed to ischemia,especially given the temporal delay. Delayed STEMI may have been related to unstableplaque rupture in the setting of extensive atherosclerotic burden. It is feasible thatcoronary hyperemia contributed to this phenomenon.It also bears mentioning that STEMI might only be coincident with prior stress testingand that pharmacological testing was not actually causative. To our knowledge, this isthe first case describing STEMI hours after dipyridamole stress testing in comparisonto previously reported cases that described such complications during the period ofpharmacological stress. This case adds to the literature on the importance of continuouscardiac monitoring in patients following pharmacological stress tests.WHAT WE HAVE LEARNED?• Dipyridamole myocardial perfusion imaging is relatively safe.• Coronary ischemia is one of the complications during nuclear stress testing.• Myocardial ischemia may stem from vasodilator-induced myocardial injury, coronaryvasospasm, or spontaneous plaque rupture.REFERENCES[1] Zamorano J, Duque A, Baquero M, Moreno R, Almeria C, Rodrigo JL, et al. Stress echocardiography in thepre-operative evaluation of patients undergoing major vascular surgery [in Spanish]. Rev Esp Cardiol.2002;55:121–126.[2] Lette J, Tatum JL, Fraser S, Miller D, Waters DD, Heller G, Stanton EB, et al. Safety of dipyridamole testingin 73.806 patients. J Nucl Cardiol. 1995;2:3–17.[3] Leppo JA. Dipyridamole-thallium imaging: the lazy man’s stress test. J Nucl Med . 1989;30:281–287.[4] Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclearcardiology procedures: stress, protocols, and tracers. J Nucl Cardiol. 2016;23:606–639.[5] Li KFC, Ho HH, Yew MS. A case report of dipyridamole stress-induced ST depression progressing toST-elevation myocardial infarction despite intravenous aminophylline: steal, spasm, or somethingelse? Eur Heart J Case Rep. 2019;3(2):ytz054. doi: 10.1093/ehjcr/ytz054. PMID: 31449606; PMCID:PMC6601234.[6] Hansen CL, Williams E. Severe transmural myocardial ischemia after dipyridamole administrationimplicating coronary steal. Clin Cardiol. 1998;21(4):293–296. doi: 10.1002/clc.4960210413. PMID:9562942; PMCID: PMC6656092.[7] Mutlu H, Leppo J. Coronary steal and ST elevation during dipyridamole stress testing leading to coronaryartery bypass grafting. J Nucl Cardiol. 2007;14(6):892–897. doi: 10.1016/j.nuclcard.2007.09.004. Epub2007 Oct 18. PMID: 18022117.[8] Safi AM, Pillai N, Rachko M, Chaudhry K, Stein RA. Dipyridamole-induced ST-segment elevationindicative of transmural myocardial ischemia–a case report. Angiology . 2001;52(8):553–557. doi:10.1177/000331970105200808. PMID: 11512695.[9] Kwai AH, Jacobson AF, McIntyre KM, Williams WH, Tow DE. Persistent chest pain following oraldipyridamole for thallium 201 myocardial imaging. Eur J Nucl Med . 1990;16(8-10):745–746. doi:10.1007/BF00998182. PMID: 2384110.[10] Li KFC, Ho HH, Yew MS. A case report of dipyridamole stress-induced ST depression progressing toST-elevation myocardial infarction despite intravenous aminophylline: steal, spasm, or somethingelse? Eur Heart J Case Rep. 2019;3(2):ytz054. doi: 10.1093/ehjcr/ytz054. PMID: 31449606; PMCID:PMC6601234.[11] Díaz-Castro O, Fernández-López J, Campos L, Calvo F, Mantilla R, Goicolea J. Elevación del segmento STdurante una tomografía computarizada por emisión de fotones simples con dipiridamol en ausenciade lesiones coronarias [ST segment elevation during dipyridamole stress testing in a patient withoutcoronary lesions]. Rev Esp Cardiol. 2004;57(2):177–179. Spanish. PMID: 14967116.Page 8 of 8Al Hennawi et al. GCSP 2023:23[12] West J, Bellet S, Manzoli U, Miiller 0. Effects of persantin (RA8), a new coronary vasodilator, on coronaryblood flow and cardiac dynamics in the dog. Circ Kes. 1962;10:3544.[13] Wendt V, Sunderrneyer J, den Bakker P. Bing R: The relationship between coronary blood flow,myocardial oxygen consumption and cardiac work as influenced by persantin. Am J Ccirdiol.1962;9:449454.[14] Picano E, Lattanzi F, Masini M, Distante A, L’ Abbate A. Aminophylline termination of dipyridamole stressas a trigger of coronary vasospasm in variant angina. Am J Cardiol. 1988;62:694–697.[15] Weinmann P, le Gudulec D, Moretti JL. Coronary spasm induced by dipyridamole during dipyridamolescintigraphy. Int J Cardiol. 1994;43:75–78.

Dipyridamole-Induced Stemi: Case Report and Review of the Literature

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Dipyridamole-Induced Stemi: Case Report and Review of the Literature

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