The Diagnostic Challenge of Dipyridamole-atropine Stress Echocardiography in a Patient with Myocardial Bridge

Abstract

A 60-year-old male patient was submitted to dipyridamole-atropine stress echocardiography (DSE) for chest pain during exertion. At rest, no electrocardiographic (ECG) and transthoracic echocardiographic (TTE) abnormalities were observed. After dipyridamole infusion, the patient complained a mild chest discomfort, without ECG changes and TTE wall-motion abnormalities. Subsequently, worsening of the anginal symptoms combined with descending ST-depression and T-negative waves occurred after atropine and unexpectedly, aminophylline administration. Coronary angiography was performed showing a myocardial bridge (MB) of the left anterior descending artery. The occurrence, during DSE, of worsening ischemic abnormalities after atropine and aminophylline administration may be a particular diagnostic feature of MB.

Keywords: Dipyridamole stress echocardiography; left anterior descending artery; longitudinal strain; myocardial bridge.

Figure 1

Electrocardiogram at rest

Figure 2

Two-dimensional strain analysis showing global longitudinal strain at rest (upper panel) and at peak dose of dipyridamole (lower panel)

Figure 3

Electrocardiogram after injection of atropine and aminophylline

Figure 4

Coronary angiography images in diastole (left) and systole (right) showing myocardial bridge of the left anterior descending artery with systolic “milking”

Figure 5

Angiographic images did not change after intracoronary nitroglycerine administration