Nuclear Imaging In Cardiology Cme
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Nuclear ImagingNuclear Imagingin Cardiologyin Cardiology
Dr. Muhammad AyubDr. Muhammad AyubDiplomate Certification Board of Nuclear CardiologyDiplomate Certification Board of Nuclear Cardiology
Diplomate Certification Board of Cardiovascular CTDiplomate Certification Board of Cardiovascular CT
Assistant Professor of CardiologyAssistant Professor of Cardiology
Punjab Institute of Cardiology, LahorePunjab Institute of Cardiology, Lahore
Applications of Nuclear Applications of Nuclear CardiologyCardiology
Coronary Artery DiseaseCoronary Artery Disease Assessment of LV /RV functionAssessment of LV /RV function Cardiomyopathy /MyocarditisCardiomyopathy /Myocarditis Valvular Heart DiseaseValvular Heart Disease Cardiac ShuntsCardiac Shunts Secondary HypertensionSecondary Hypertension Pulmonary HypertensionPulmonary Hypertension Assessment of Cardiac TransplantAssessment of Cardiac Transplant
Coronary Artery DiseaseCoronary Artery Disease Diagnosis of CADDiagnosis of CAD Assessment of Prognosis Assessment of Prognosis Risk StratificationRisk Stratification
Stable /Unstable AnginaStable /Unstable Angina Post MIPost MI PerioperativePerioperative DiabeticsDiabetics
Assessment of Myocardial ViabilityAssessment of Myocardial Viability Assessment of Revascularization ProcedureAssessment of Revascularization Procedure Acute chest pain management in ERAcute chest pain management in ER
Detection of CAD
68
81
92 89 87
0%
20%
40%
60%
80%
100%
Sensitivity
77
87 8490 89
Specificity
Ex ECG (150 studies) Stress echo (14 studies)Thallium SPECT (6 studies) MIBI SPECT(3 studies)Tetrofosmin SPECT
Adapted from Beller GA
Diagnostic Accuracy: Bayesian Diagnostic Accuracy: Bayesian AnalysisAnalysis
MPI
Pretest
ECG
+
+
+
5% 35% 80%20% 75% 95%
1% 75% 95%5% 25% 99%
Higher Sensitivity/Specificity Enhances Posttest Likelihood
+
+ +
Posttest
Posttest
10% 90%50%
Normal ScanNormal Scan
Visual scoringVisual scoring
1
0
4
2
4
4
1
2
2
3
4
4
100%
70
50
30
10
0
4 normal 100 - 70%
3 mild 70 - 50%
2 moderate 50 - 30%
1 severe 30 - 10%
0 absent 10 - 0%
Score
LADLAD
Left MainLeft Main
LCxLCx
Multi Vessel DiseaseMulti Vessel Disease
CADCAD
Assessment of InterventionAssessment of Intervention
Post CABG
Pre CABG
Pre Pre PTCAPTCA
Post PTCAPost PTCA
Coronary Artery DiseaseCoronary Artery Disease
Assessment of Assessment of PrognosisPrognosis
Risk Stratification: Risk Stratification: PrognosisPrognosis
Low Low <1% per year<1% per year
Intermediate Intermediate
1-3% per year1-3% per year High High
>3% per year>3% per year
Adapted from Gibbons RJ, et al. J Am Coll Cardiol. 1999;33:2092-2197.
Risk of Cardiac Death:
Normal MPI indicates good prognosisNormal MPI indicates good prognosis
5.17.4
25.0
33.5 33.7
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Clinical +Ex Clin+Ex
+Cath
Clin+Ex
+SPECT
All
P=ns
P<.01
P<.01 P=ns
2
Iskandrian AS, et al. J Am Coll Cardiol. 1993;22:665-670. Reproduced with permission. Copyright 1993 by the American College of Cardiology.
N = 316
Incremental Prognostic Incremental Prognostic ValueValue
NS=not significant
High Risk Feature of SPECT High Risk Feature of SPECT MPIMPI
Following features demonstrate >3% Following features demonstrate >3% annual mortalityannual mortality Post-stress EF <35% (99m-Technetium).Post-stress EF <35% (99m-Technetium). Stress induced large perfusion defect.Stress induced large perfusion defect. Stress induced multiple perfusion defects of Stress induced multiple perfusion defects of
moderate size.moderate size. Large, fixed perfusion defect with LV dilation or Large, fixed perfusion defect with LV dilation or
increased lung uptake (Thallium-201).increased lung uptake (Thallium-201). Stress induced moderate perfusion defect with Stress induced moderate perfusion defect with
LV dilation or increased lung uptake (Thallium LV dilation or increased lung uptake (Thallium 201).201).
Gibbons et al. ACC/AHA/ACP-ASIM Chronic Stable Angina Guidelines. JACC. 1999.33: 2092-197.
Patients with Suspected CAD
Anti-anginal TherapyAggressive RFM
Cath if symptoms refractory to therapy
A Risk-based Approach to A Risk-based Approach to Suspected CADSuspected CAD
Cardiac CathRFM
Mod-Severely Abnormal Intermediate to high
risk for cardiac death or MI
ReassuranceRisk factor (RFM)
modification
NormalVery low risk
for cardiac death, Low risk for MI
Mildly AbnormalLow risk for cardiac death, Intermediate
risk for MI
Tc-99 Myocardial Perfusion with Gated SPECT
High Risk StudyHigh Risk Study
Low Risk Study Low Risk Study Mild 3VDMild 3VD
Established Prognostic Role
Prognostic role of perfusion imaging has documented accuracy of risk assessment in the following populations and conditions:
• CAD – suspected or known• Angina – stable or unstable• Women• Diabetics• Post-MI• Post-revascularization • Preoperative screening for
noncardiac surgery
Coronary Artery Coronary Artery DiseaseDiseaseAcute Chest Pain Acute Chest Pain
Management in ERManagement in ER
Myocardial Scintigraphy for Acute Coronary Syndromes
Onset of Symptoms
UnclearDiagnosis
Clinical Management
Sestamibi injection Sestamibi SPECT
One Hour
AbAbnn
AbAbnn
NINININI
Chest PainChest PainChest PainChest Pain + Non-diagnostic + Non-diagnostic ECG)ECG)+ Non-diagnostic + Non-diagnostic ECG)ECG)
Rest Rest SPECTSPECTRest Rest
SPECTSPECT
AbAbnn
AbAbnn
NINININI
ImmediateImmediateEx ECGEx ECG
ImmediateImmediateEx ECGEx ECG
2 h
ours
2 h
ours
2 h
ours
2 h
ou
rs
NINININI AbAbnn
AbAbnn
Ex ECGEx ECGEx ECGEx ECG
NINININI AbAbnn
AbAbnn
13 h
ou
rs1
3 h
ou
rs1
3 h
ou
rs1
3 h
ou
rs
3 sets3 sets3 sets3 sets
EnzymesEnzymesEnzymesEnzymes
Patients with Abnormal Tests are Admitted
Infarct Imaging Infarct Imaging
“Hot Spot” Annexin V Perfusion Imaging
THE LANCET • Vol 356 • July 15, 2000
Coronary Artery Coronary Artery DiseaseDisease
Assessment of LV FunctionAssessment of LV Function
Gated Myocardial Perfusion SPECT
Courtesy of M Atiar Rahman, MD, of Ochsner Clinic. LA
Perfusion and FunctionGated Myocardial Perfusion SPECT
LV FunctionLV Function
Blood pool gated SPECT
Assessment of Myocardial Assessment of Myocardial ViabilityViability
Patients with CAD and LVF carry bad Patients with CAD and LVF carry bad prognosisprognosis
Patients with CAD and LVF have Patients with CAD and LVF have higher mortality during higher mortality during revascularization procedurerevascularization procedure
Ischemic LVF patients can benefit Ischemic LVF patients can benefit from revascularization procedures if from revascularization procedures if there is evidence of myocardial there is evidence of myocardial viability viability
Hibernating MyocardiumHibernating Myocardium
Scar MyocardiumScar Myocardium
MyocarditisMyocarditisIndium 111 Antimyosin AB ScanIndium 111 Antimyosin AB Scan
Valvular Heart DiseaseValvular Heart Disease Baseline and Exercise EF Baseline and Exercise EF MUGA ScanMUGA Scan Regurgitation Index (Stroke Volume Ratio)Regurgitation Index (Stroke Volume Ratio)
LV Stroke Counts – RV Stroke CountsRegurg Fraction = ______________________________
LV Stroke Counts
LV Stroke Counts SVR = _____________________ RV Stroke Counts
SVR >2SVR >2Moderately Severe RegurgitationModerately Severe Regurgitation SVR >3SVR >3Severe RegurgitationSevere Regurgitation
Cardiac Transplant AssessmentCardiac Transplant AssessmentIndium-111 ImagingIndium-111 Imaging
Pulmonary Pulmonary HypertensionHypertension
Pulmonary EmbolismPulmonary Embolism V/Q V/Q ScanScan
Left to Right Shunt Left to Right Shunt First Pass First Pass StudyStudy
Normal First Pass StudyNormal First Pass Study
Left to Right Shunt
Qp/Qs= 2.6
A ratio of less than A ratio of less than 1.5 indicates a small 1.5 indicates a small left-to-right shunt. A left-to-right shunt. A ratio of 2.0 or more ratio of 2.0 or more indicates a large indicates a large left-to-right shuntleft-to-right shunt
Right to Left ShuntBody uptake of MAA > 6% of lung uptake
Secondary Secondary HypertensionHypertension
Renal Artery StenosisRenal Artery Stenosis Captopril Captopril Renogram StudyRenogram Study
PheochromocytomaPheochromocytoma I123 MIBG I123 MIBG ScanScan
PheochromocytomaPheochromocytomaII123123 MIBG Scan MIBG Scan
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