ABC | Volume 114, Nº2, February 2020

Update Update of the Brazilian Guideline on Nuclear Cardiology – 2020 Arq Bras Cardiol. 2020; 114(2):325-429 Figure 29 – Case 4 - Myocardial perfusion scintigraphy within normality. Images acquired with dedicated cardiac equipment, equipped with solid cadmium-zinc-tellurium detectors. events. Furthermore, a current register known as CONFIRM has accumulated data that definitively suggest that, in the presence of non-obstructive CAD, 240 evolution may be worse in patients without CAD. It has, thus, become evident that the anatomical technique with angio-CT is identifying coronary atherosclerosis earlier. This set of information definitively represents a change of paradigm in the medical decision- making process. In this situation where CAD is identified, medical management will be geared toward more aggressive prevention of modifiable risk factors and minute observation of possible symptoms that translate to disease instability. In the absence of ischemia, revascularization procedures should not be considered. 5. Patient with high CS and abnormal MPS Clinical history : female, age 68, asymptomatic, with intermediate-risk Framingham score. Performed CS for risk restratification. Images: reproduced with permission of Vitola JV. 234 Findings: The resulting CS was high, at 1,282, according to the Agatston score, placing this patient in the 99% percentile (Figure 30).With this finding, functional evaluationwas indicated, using MPS with MIBI- 99m Tc associated with exercise. The patient exercised for 7.5 minutes in the Bruce protocol, showing ST- segment depression of up to 3 mm during peak stress, with a varying aspect which tended toward descending inmultiple leads, without symptoms (Figure 31). With these findings, the Duke score (DS) =exercise time inminutes – (5×ST deviation) – (4× angina index), or DS =+7.5 – (5×3) – (4 x 0) = – 7.5 , resulting in classification as intermediate risk. In the perfusion images, the presence of transient reduced uptake was evidently observed, involving the middle and distal portions of the anteroseptal and anterior walls and apex of the LV, with accentuated intensity and medium extent, compatible with significant ischemia in the territory of the anterior descending artery (Figure 32). Furthermore, mild transient dilation of the LV cavity was observed during stress, in addition to radiopharmaceutical uptake in the RV wall, which are high-risk markers. Comments: Evidence in the literature has supported the use of CS for risk restratification in patients who have intermediate clinical risks (using, for instance the Framingham or the global risk score), but who are in asymptomatic phases. The higher the CS, the higher the risk will be; not coincidentally, the probability of silent ischemia will also be higher, and this, in turn, increases the patient risks even further. Data have demonstrated that, when CS values are between 400 and 999, the probability of perfusion defects reaches up to 29%, and when values are > 1,000, the probability increases to 39%. 241 Brazilian data from Cerci et al. have reported similar information, with an ischemia prevalence of 34% in patients with CC over 400. 242 Within medical orientation, rigorous preventative measures have shown evident benefits in individuals with high CS. Caution, however, is recommended when indicating revascularization procedures, emphasizing the absence of formal indication, 371