Differential diagnosis, investigations, and treatment:
An initial cardiac evaluation revealed elevated troponin and pro-BNP levels. Echocardiogram showed severe global hypokinesis with left ventricular ejection fraction (LVEF) of 20%. Coronary angiography revealed multivessel coronary artery disease including chronic total occlusion of the right coronary artery with collaterals from the left coronary system (Figure 1). To fully characterize the territories needing revascularization, MRI viability study was obtained, cardiac magnetic resonance (CMR) showed viable myocardium at RCA, circumflex, and predominantly viable LAD, except for distal apical septal segment. (Figure 2). Due to the severity of CAD, the patient was referred for coronary artery bypass grafting (CABG), however, was deemed not a good candidate by the heart team.