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Principles of nuclear cardiology
History
• Hermann blumgart-1927-injected radon to
measure circulation time
• Liljestrand-1939-normal blood volume
• Myron ...
• 1980s-SPECT using rotating anger camera
• 1990-technetium99m based agents and gated
SPECT
• 90% of SPECT in U.S use tech...
SPECT
single photon emission computed tomography
Basic concept
• Intravenously injected radiotracer distributes
to myocardium proportional to blood flow
• Gamma camera cap...
SPECT image display
• Short axis images-perpendicular to long axis of
the heart,displayed from apex to base
• Vertical lon...
SPECT
SPECT perfusion tracers
• Thallium 201
• Technetium–99m
– Sestamibi (Cardiolyte)
– Tetrafosmin (Myoview)
– Teboroxime
• Du...
Thallium-201
• Monovalent cation,property similar to
potassium
• Half life 73 hours,emits 80keV photons,t½
73hrs,85% first...
• Differential washout-clearance is more rapid
from normal myocardium
• Hyperinsulinemic states reduce blood
conc.&slow re...
• Thallium protocols-
– Stress protocols-injected at peak stress and
images taken at peak stress and at 4 hrs,24hrs
– Reve...
• Stress/redistribution/reinjection method
commonly used
• Reinjection if fixed defects seen at 4 hrs
• Timing of stress i...
Technetium-99m labelled tracers
• Half life 6 hrs,140keV photons,60% extraction
• Uptake by passive distribution by gradie...
• Tc99m tracers bound by mitochondria.limiyed
washout occurs.so imaging can commence
later and can be repeated
• 2 day image protocol better for image quality
• Most common-same day low dose rest/high
dose stress-disadvantage is redu...
Dual isotope protocol
• Anger camera can collect image in different
energy windows
• Thallium at rest followed by Tc 99m t...
Radionuclide Properties
Property Thallous Chloride Tc-Sestamibi
Chemistry +1 cation, hydrophilic +1 cation, lipophilic
hal...
Stress protocols
• Dipyridamole infusion for 4 min-isotope
injection 3 min after infusion
• Adenosine infusion for 6 min-isotope given 3
mi...
Interpretation and reporting
• Myocardium devided into 17 segments on the
basis of 3 short axis and a long axis slice
• Pe...
Visual Analysis of Perfusion SPECT
• 0-normal uptake,
• 1-mildly reduced uptake,
• 2-moderately reduced uptake,
• 3-severe...
• bull̒s eye polar plot-two dimensional
compilation of all three dimensional short axis
perfusion data
Ant
Inf
LatSep
Apex  Base
Ant
Inf
Apex
Septum  Lateral
Apex
Sep Lat
Inferior  Anterior
Stress
Stress
Stress
Rest
Rest
R...
Ant
Inf
LatSep
Apex  Base
Ant
Inf
Apex
Septum  Lateral
Apex
Sep Lat
Inferior  Anterior
Stress
Stress
Stress
Rest
Rest
R...
Ant
Inf
LatSep
Apex  Base
Ant
Inf
Apex
Septum  Lateral
Apex
Sep Lat
Inferior  Anterior
Stress
Stress
Stress
Rest
Rest
R...
Interpretation of the Findings-SPECT
Stress Rest Interpretation
• No defects No defects Normal
• Defect No defect Ischemia...
Additional signs
• Lung uptake of thallium
• Transient ischemic dilatation of left ventricle
Thallium-201 Lung Uptake
• ↑ lung uptake of thallium following stress -marker of severe
CAD,elevation of PCWP,↓EF
• ↑PCWP-...
TID: transit Ischemic Dilation (Stress
induced LV Cavity Dilation)
• Severe, extensive CAD (usually with classic ischemic ...
Variations
• Dropout of the upper septum
• Apical thinning
• Lateral wall may appear brighter than septum
• Minimised by r...
Technical artifacts
• Breast attenuation-
– Minimised by Tc99m agents,ecg gated SPECT
– Presence of preserved wall motion ...
• LBBB-
– isolated reversible perfusion defects of septum
– Heterogeneity of flow b/w LAD &LCx due to
delayed septal relax...
• Combined SPECT/CT or PET/CT scanners-
complementary anatomical and functional
information
Gated SPECT
• Simultaneous assessment of LV function and
perfusion
• Each R-R interval is devided into prespecified
number...
• Normal regional systolic function-brightening
of wall during systole
• Quantitative analysis of LV function-three
dimens...
Radionuclide ventriculography
• MUGA scanning-multiple gated acquisition
– Tc 99m labelled r.b.c or albumin
– Image constr...
• First pass RVG-i.v injected radioactive tracer
passes through rt.chambers-lungs-lt.chambers
• Tc99m DTPA preferred
• RAO...
PET
• Radiotracers labelled with positron emitting
isotopes
• Perfusion tracers-Rb82 and n13 ammonia
• Metabolic tracer-F1...
Perfusion tracers
• Diffusible tracers-O-15-accumulate and wash
out.
• Non diffusible-Rb82,N13ammonia
• Rb82-generator pro...
Advantage of PET
• Higher spatial resolution
• Improved attenuation correction
• Quantification regional blood flow
– SPEC...
Limitations
• High cost
• Requirement of cyclotron
• Short half life-pharmacological stress only
Metabolic tracers
• C-11 palmitate
• I-123 BMIPP-Ischemic memory-fatty acid
metabolism suppressed for longer time after
an...
• FDG uptake in regions with reduced blood
flow at rest –marker of hibernation
• FDG studies performed after 50 to 75 gm
g...
• Enhanced FDG uptake relative to blood flow
referred to as PET mismatch pattern indicative
of viable myocardium
Viability PET Study
• Traditionally the gold standard
• Two sets of resting images to detect viable and
hibernating myocar...
*
PET Viability
Scan Patterns
Contractility Perfusion Metabolism
Normal N N N
Stunning - N N -
Hibernation
Scar
Guidelines
• Acute syndromes
– Assessment of patients presenting to ED with
chest pain
– Diagnosis of AMI when other measu...
Chronic syndromes-
recommendations
Class1-
• Exercise SPECT for identifying location ,severity of
ischemia in pts without ...
• Class 2a-
– 3-5 yrs after revascularisation in asymptomatic
patients
– As initial test in high risk patients(>20% 10yr r...
Indications for PET for risk stratification of patients
with intermediate likelihood of CAD
CLASS1-
– SPECT study equivoca...
Risk Stratification
• Normal perfusion imaging after adequate
stress: very low cardiac event rate < 1%
• Small fixed defec...
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
Principles of nuclear cardiology
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Principles of nuclear cardiology Slide 1 Principles of nuclear cardiology Slide 2 Principles of nuclear cardiology Slide 3 Principles of nuclear cardiology Slide 4 Principles of nuclear cardiology Slide 5 Principles of nuclear cardiology Slide 6 Principles of nuclear cardiology Slide 7 Principles of nuclear cardiology Slide 8 Principles of nuclear cardiology Slide 9 Principles of nuclear cardiology Slide 10 Principles of nuclear cardiology Slide 11 Principles of nuclear cardiology Slide 12 Principles of nuclear cardiology Slide 13 Principles of nuclear cardiology Slide 14 Principles of nuclear cardiology Slide 15 Principles of nuclear cardiology Slide 16 Principles of nuclear cardiology Slide 17 Principles of nuclear cardiology Slide 18 Principles of nuclear cardiology Slide 19 Principles of nuclear cardiology Slide 20 Principles of nuclear cardiology Slide 21 Principles of nuclear cardiology Slide 22 Principles of nuclear cardiology Slide 23 Principles of nuclear cardiology Slide 24 Principles of nuclear cardiology Slide 25 Principles of nuclear cardiology Slide 26 Principles of nuclear cardiology Slide 27 Principles of nuclear cardiology Slide 28 Principles of nuclear cardiology Slide 29 Principles of nuclear cardiology Slide 30 Principles of nuclear cardiology Slide 31 Principles of nuclear cardiology Slide 32 Principles of nuclear cardiology Slide 33 Principles of nuclear cardiology Slide 34 Principles of nuclear cardiology Slide 35 Principles of nuclear cardiology Slide 36 Principles of nuclear cardiology Slide 37 Principles of nuclear cardiology Slide 38 Principles of nuclear cardiology Slide 39 Principles of nuclear cardiology Slide 40 Principles of nuclear cardiology Slide 41 Principles of nuclear cardiology Slide 42 Principles of nuclear cardiology Slide 43 Principles of nuclear cardiology Slide 44 Principles of nuclear cardiology Slide 45 Principles of nuclear cardiology Slide 46 Principles of nuclear cardiology Slide 47 Principles of nuclear cardiology Slide 48 Principles of nuclear cardiology Slide 49 Principles of nuclear cardiology Slide 50 Principles of nuclear cardiology Slide 51 Principles of nuclear cardiology Slide 52 Principles of nuclear cardiology Slide 53 Principles of nuclear cardiology Slide 54 Principles of nuclear cardiology Slide 55 Principles of nuclear cardiology Slide 56 Principles of nuclear cardiology Slide 57 Principles of nuclear cardiology Slide 58 Principles of nuclear cardiology Slide 59 Principles of nuclear cardiology Slide 60 Principles of nuclear cardiology Slide 61 Principles of nuclear cardiology Slide 62 Principles of nuclear cardiology Slide 63 Principles of nuclear cardiology Slide 64 Principles of nuclear cardiology Slide 65 Principles of nuclear cardiology Slide 66 Principles of nuclear cardiology Slide 67 Principles of nuclear cardiology Slide 68 Principles of nuclear cardiology Slide 69 Principles of nuclear cardiology Slide 70 Principles of nuclear cardiology Slide 71 Principles of nuclear cardiology Slide 72 Principles of nuclear cardiology Slide 73 Principles of nuclear cardiology Slide 74 Principles of nuclear cardiology Slide 75 Principles of nuclear cardiology Slide 76 Principles of nuclear cardiology Slide 77 Principles of nuclear cardiology Slide 78 Principles of nuclear cardiology Slide 79 Principles of nuclear cardiology Slide 80 Principles of nuclear cardiology Slide 81 Principles of nuclear cardiology Slide 82 Principles of nuclear cardiology Slide 83 Principles of nuclear cardiology Slide 84 Principles of nuclear cardiology Slide 85 Principles of nuclear cardiology Slide 86 Principles of nuclear cardiology Slide 87
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Principles of nuclear cardiology

  1. 1. Principles of nuclear cardiology
  2. 2. History • Hermann blumgart-1927-injected radon to measure circulation time • Liljestrand-1939-normal blood volume • Myron prinzmetal-1948- radiolabelled albumin • Hal anger-1952-gamma camera-beginning of clinical nuclear cardiology • 1976-thallium201-two dimensional planar imaging
  3. 3. • 1980s-SPECT using rotating anger camera • 1990-technetium99m based agents and gated SPECT • 90% of SPECT in U.S use technetium and 90% are gated SPECT
  4. 4. SPECT single photon emission computed tomography
  5. 5. Basic concept • Intravenously injected radiotracer distributes to myocardium proportional to blood flow • Gamma camera captures the photons, converts to digital data and displays it as a scintillation event • Parallel hole collimator-better localisation of source • Photomultiplier tubes-conversion of signals • Final result-multiple tomograms of radiotracer distribution
  6. 6. SPECT image display • Short axis images-perpendicular to long axis of the heart,displayed from apex to base • Vertical long axis-parallel to long axis of heart and parallel to long axis of body • Horizontal long axis-parallel to long axis of heart,perpendicular to VLA slice
  7. 7. SPECT
  8. 8. SPECT perfusion tracers • Thallium 201 • Technetium–99m – Sestamibi (Cardiolyte) – Tetrafosmin (Myoview) – Teboroxime • Dual Isotope – Thallium injected for resting images – Tech -99m injected at peak stress
  9. 9. Thallium-201 • Monovalent cation,property similar to potassium • Half life 73 hours,emits 80keV photons,t½ 73hrs,85% first pass extraction • Peak myocardial concentration in 5 min, rapid clearance from intravascular compartment • Redistribution of thallium-begins 10-15 min.after ,related to conc.gradient of thallium between myocyte and blood
  10. 10. • Differential washout-clearance is more rapid from normal myocardium • Hyperinsulinemic states reduce blood conc.&slow redistribution.so fasting recommended
  11. 11. • Thallium protocols- – Stress protocols-injected at peak stress and images taken at peak stress and at 4 hrs,24hrs – Reversal of a thallium defect marker of reversible ischemia – Rest protocols-thallium defect reversibility from initial rest images to delayed redistribution images reflect viable myocardium with resting hypoperfusion – Initial defect persists-irreversible defect
  12. 12. • Stress/redistribution/reinjection method commonly used • Reinjection if fixed defects seen at 4 hrs • Timing of stress image-early • Rest redistribution image for resting ischemia/viability
  13. 13. Technetium-99m labelled tracers • Half life 6 hrs,140keV photons,60% extraction • Uptake by passive distribution by gradient • Minimal redistribution-require two separate injections-one at peak stress and one at rest • Single day study-first injected dose is low • Two day study-higher doses injected both rest and stress-optimise myocardial count rate- larger body habitus
  14. 14. • Tc99m tracers bound by mitochondria.limiyed washout occurs.so imaging can commence later and can be repeated
  15. 15. • 2 day image protocol better for image quality • Most common-same day low dose rest/high dose stress-disadvantage is reduction in stress defect contrast. • Viability assessment improved by NTG prior to rest study
  16. 16. Dual isotope protocol • Anger camera can collect image in different energy windows • Thallium at rest followed by Tc 99m tracer at peak stress • If there is rest perfusion defect,redistribution imaging taken either 4 hrs prior or 24hrs after Tc99m injection
  17. 17. Radionuclide Properties Property Thallous Chloride Tc-Sestamibi Chemistry +1 cation, hydrophilic +1 cation, lipophilic half life 73 hrs 6 hours Photon energy 68-80 keV 140 keV Uptake Active: Na-K ATPase pump Passive diffusion (if intact membrane potentials) Extraction fraction 85% 66% Heart uptake 4% 1.2% Redistribution Redistributes Fixed
  18. 18. Stress protocols
  19. 19. • Dipyridamole infusion for 4 min-isotope injection 3 min after infusion • Adenosine infusion for 6 min-isotope given 3 min into infusion
  20. 20. Interpretation and reporting • Myocardium devided into 17 segments on the basis of 3 short axis and a long axis slice • Perfusion graded from 0(normal perfusion) to 4(no uptake) • SSS-summed stress score-stress perfusion abnormality • SRS –summed rest score-extent of infarction • SDS-summed difference score-stress induced ischemia
  21. 21. Visual Analysis of Perfusion SPECT • 0-normal uptake, • 1-mildly reduced uptake, • 2-moderately reduced uptake, • 3-severely reduced uptake, and • 4-no uptake
  22. 22. • bull̒s eye polar plot-two dimensional compilation of all three dimensional short axis perfusion data
  23. 23. Ant Inf LatSep Apex  Base Ant Inf Apex Septum  Lateral Apex Sep Lat Inferior  Anterior Stress Stress Stress Rest Rest Rest Normal
  24. 24. Ant Inf LatSep Apex  Base Ant Inf Apex Septum  Lateral Apex Sep Lat Inferior  Anterior Stress Stress Stress Rest Rest Rest Reversible Ischeamia, defect appears at stress and disappears during rest
  25. 25. Ant Inf LatSep Apex  Base Ant Inf Apex Septum  Lateral Apex Sep Lat Inferior  Anterior Stress Stress Stress Rest Rest Rest Fixed Scar, defect is seen in both stress and rest
  26. 26. Interpretation of the Findings-SPECT Stress Rest Interpretation • No defects No defects Normal • Defect No defect Ischemia • Defect Defect Scar/ hibernating • Defect location (anterior, posterior, lateral, or septal wall), size (small, medium, or big), severity (mild, moderate, absent), degree of reversibility at rest (completely reversible, partially reversible, irreversible) • Regional wall motion, EDV, ESV, EF (Stress-induced ischemia)
  27. 27. Additional signs • Lung uptake of thallium • Transient ischemic dilatation of left ventricle
  28. 28. Thallium-201 Lung Uptake • ↑ lung uptake of thallium following stress -marker of severe CAD,elevation of PCWP,↓EF • ↑PCWP-slow pulmonary transit-more extraction • Minimal splanchnic uptake,early image after stress-lung uptake more apparent in thallium • More liver uptake,delayed imaging-lung uptake missed with Tc99m
  29. 29. TID: transit Ischemic Dilation (Stress induced LV Cavity Dilation) • Severe, extensive CAD (usually with classic ischemic defect) Left Main Prox LAD MVD diffuse subendocardial ischemia
  30. 30. Variations • Dropout of the upper septum • Apical thinning • Lateral wall may appear brighter than septum • Minimised by review of series of normal volunteers
  31. 31. Technical artifacts • Breast attenuation- – Minimised by Tc99m agents,ecg gated SPECT – Presence of preserved wall motion and thickening • Inferior wall attenuation – Diaphragm overlapping inferior wall – Minimised by gated SPECT,prone position • Extracardiac tracer uptake – Repeat imaging,drink cold water to clear tracer from visceral organs
  32. 32. • LBBB- – isolated reversible perfusion defects of septum – Heterogeneity of flow b/w LAD &LCx due to delayed septal relaxation – Reduced O2 demand due to late septal contraction,when wall stress is less • HCM- – due to ASH,appearance of lateral perfusion defect
  33. 33. • Combined SPECT/CT or PET/CT scanners- complementary anatomical and functional information
  34. 34. Gated SPECT • Simultaneous assessment of LV function and perfusion • Each R-R interval is devided into prespecified number of frames • Frame one represent end diastole,middle frames end systole • An average of several hundred beats of a particular cycle length acquired over 8-15 min.
  35. 35. • Normal regional systolic function-brightening of wall during systole • Quantitative analysis of LV function-three dimensional display representing global LV function created by information from all tomographic slices-EF and LV volumes calculated
  36. 36. Radionuclide ventriculography • MUGA scanning-multiple gated acquisition – Tc 99m labelled r.b.c or albumin – Image constructed over an average cardiac cycle by e.c.g gating,16-32 frames /cycle – Image acquired in antr.,LAO, left lateral projections – Size of chambers,RWMA,LV function – Time activity curve-LV volumes
  37. 37. • First pass RVG-i.v injected radioactive tracer passes through rt.chambers-lungs-lt.chambers • Tc99m DTPA preferred • RAO projection • 2-5 cycles summed for RV phase,5-7 for LV phase • Time activity curves generated-quantitative analysis
  38. 38. PET • Radiotracers labelled with positron emitting isotopes • Perfusion tracers-Rb82 and n13 ammonia • Metabolic tracer-F18 FDG • Beta decay-positron emission • Annihilation-collide with electron-give two gamma rays of 511keV-travel in opp.direction • PET scanner detects opposing photons in coincidence-spatial and temporal resolution
  39. 39. Perfusion tracers • Diffusible tracers-O-15-accumulate and wash out. • Non diffusible-Rb82,N13ammonia • Rb82-generator produced,t½76s.
  40. 40. Advantage of PET • Higher spatial resolution • Improved attenuation correction • Quantification regional blood flow – SPECT may fail to detect balanced ischemia in multivessel CAD – ↓blood flow reserve by PET –early identification of CAD • Higher sensitivity and specificity(95%)for detection of CAD
  41. 41. Limitations • High cost • Requirement of cyclotron • Short half life-pharmacological stress only
  42. 42. Metabolic tracers • C-11 palmitate • I-123 BMIPP-Ischemic memory-fatty acid metabolism suppressed for longer time after an ischemic event • F18 FDG-imaging myocardial glucose utilisation with PET – Phosphorylated and trapped in myocardium – Uptake may be increased in hibernating but viable myocardium
  43. 43. • FDG uptake in regions with reduced blood flow at rest –marker of hibernation • FDG studies performed after 50 to 75 gm glucose loading 1-2 hrs prior to injection – ↑glucose metabolism,FDG uptake and improves image quality
  44. 44. • Enhanced FDG uptake relative to blood flow referred to as PET mismatch pattern indicative of viable myocardium
  45. 45. Viability PET Study • Traditionally the gold standard • Two sets of resting images to detect viable and hibernating myocardium: – Perfusion image (usually with N-13 ammonia or rubidium-82) – Glucose metabolic image (with F-18 fluorodeoxyglucose = FDG)
  46. 46. *
  47. 47. PET Viability Scan Patterns Contractility Perfusion Metabolism Normal N N N Stunning - N N - Hibernation Scar
  48. 48. Guidelines • Acute syndromes – Assessment of patients presenting to ED with chest pain – Diagnosis of AMI when other measures non diagnostic-Tc99m – Risk assessment,prognosis in AMI – Risk assessment,prognosis in NSTEMI/UA
  49. 49. Chronic syndromes- recommendations Class1- • Exercise SPECT for identifying location ,severity of ischemia in pts without baseline ECG abnormalities that interfere with ST seg.analysis • Adenosine SPECT for LBBB,paced rhythem,unable to exercise • To assess functional significance of an intermediate coronary lesion(25-75%) • Intermediate duke TMT score • Rpt.MPI for recent change of symptoms
  50. 50. • Class 2a- – 3-5 yrs after revascularisation in asymptomatic patients – As initial test in high risk patients(>20% 10yr risk) • Class 2 b- – Pts with cor.calcium score more than 75 percentile – Asymptomatic pts.high risk occupation
  51. 51. Indications for PET for risk stratification of patients with intermediate likelihood of CAD CLASS1- – SPECT study equivocal • Class 2a- – As initial test in patients unable to exercise – As initial test in pts. With baseline ECG abnormalities
  52. 52. Risk Stratification • Normal perfusion imaging after adequate stress: very low cardiac event rate < 1% • Small fixed defect with normal global LV function: good prognosis • High risk: (reversible defects) more than one territory, LAD (most important coronary artery), post-stress LV (left ventricular) dysfunction (LV dilatation, abnormal wall motion, decreased LVEF, lung uptake)
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