ABC | Volume 114, Nº2, February 2020

Update Update of the Brazilian Guideline on Nuclear Cardiology – 2020 Arq Bras Cardiol. 2020; 114(2):325-429 and moderate to severe intensity, suggestive of ischemia, involving predominantly the inferolateral, lateral, anterior, and anteroseptal walls of the LV, extending to the apex (Figure 25). Observe how the LV cavity dilate after physical exercise, with the appearance of diffuse hypokinesis and a drop in LVEF from 55% to 45% when comparing both stages. Comments: Given a normal ET, with a high workload or good performance, with neither angina nor ST-segment alterations, patients are generally considered to have low post-test risk, but this is not always the case, as can be seen here. Nor does a normal ET represent the absence of CAD, as potentially shown by the presence of calcium in the coronary arteries on angio-CT or by ischemia detected by a more sensitive technique, such as MPS. In accordance with the evolution of medical knowledge in this era of multimodalities, restratification, even of patients with low risk on exercise testing, has become possible, as an exception. These possibilities should be considered more frequently in patients with family history of early CAD, DM, or multiple combined risk factors, and especially in those with high clinical risk (Framingham score) or LAFB on resting ECG. The case presented exemplifies precisely this scenario of a clinically high-risk patient (multiple risk factors, including DM), with LAFB on resting ECG and low risks on ET, who was restratified to a higher level of risk via perfusion imaging, due to the presence of important ischemia and LV dysfunction during stress, which are high- risk indicators. In this condition, when these tests are in disagreement, in a young, symptomatic patient (probable ischemic equivalent) with high clinical risk confirmed on Figure 23 – Case 2 - Resting electrocardiogram suggestive of left anterior fascicular block. Resting ECG 366