This is a case of a 50-year-old male who was employed by an international oil and gas company. He had a history of unstable angina pectoris and had previously undergone elective PCI to the RCA. During a routine yearly medical checkup, a positive result emerged from a treadmill test, prompting the company to seek a cardiac consultation and inquire about the patient's eligibility for fieldwork.

The treadmill test revealed a maximum exercise time of 09:31 minutes on the Bruce Protocol, reaching 89% of the target maximum heart rate. An ischemic response was evident, characterized by a 2 mm upsloping ST depression on lead II, III, aVF, v4-v6.

Coronary angiography and invasive physiology study were done. The RCA stent remained patent, LAD myocardial bridging was notable, and there was borderline stenosis in LCx 

LCx physiology evaluation yielded nonsignificant results with a Resting Fractional Reserve (RFR) value of 0.96. Subsequently, a pressure wire was inserted across the myocardial bridging segment in the LAD, and a small cycling device was affixed to the cathlab table. The patient cycled with the wire still on the coronary, achieving 80% of the maximum heart rate. Significant physiological changes were recorded, with the RFR value dropping from 0.80 to 0.62. This finding confirmed the substantial impact of physical exercise on the myocardial bridging segment.

We recognize various methods for assessing significant occlusion in invasive coronary physiology studies. The standard procedure, inducing maximum hyperemia with adenosine, may not offer the same insights in dynamic stenosis like myocardial bridging. Pharmacological provocation with inotropes, such as dobutamine, could be used but comes with caveats due to vasodilating effects. Here, we demonstrate simultaneously conducting a physical exercise test with an invasive physiology study, offering potential for more physiologic, relatable results to explain a positive treadmill test.