Letter by Schuster and Nagel regarding article, "Predicting benefit from revascularization in patients with ischemic heart failure: imaging of myocardial ischemia and viability".

Case History: A 62-year-old male with a history of hypertension and coronary artery disease with prior stenting to the left circumflex artery presented with chest pain. Echocardiography on admission demonstrated a globally reduced ejection fraction of 10% to 15% with regional wall-motion abnormality consistent with prior anterior and inferolateral infarction. End-diastolic volume of the left ventricle (LV) was 210 mL. Coronary angiography showed evidence of multivessel disease, with 100% occlusion of the left anterior descending coronary artery, 70% in-stent restenosis of the left circumflex artery, and 90% stenosis of the posterior descending artery. To evaluate for the presence of ischemia, the patient underwent a rest-stress myocardial perfusion imaging study, which showed a large area of moderate ischemia throughout the mid left anterior descending coronary artery territory. In addition, there was a small area of scar in the proximal left circumflex artery territory (Figure 1). Clinical discussion ensued as to whether this patient would benefit from bypass surgery or percutaneous revascularization.