1
|
Han D, Hyun MC, Miller RJH, Gransar H, Slomka PJ, Dey D, Hayes SW, Friedman JD, Thomson LEJ, Berman DS, Rozanski A. 10-year experience of utilizing a stress-first SPECT myocardial perfusion imaging. Int J Cardiol 2024; 401:131863. [PMID: 38365012 DOI: 10.1016/j.ijcard.2024.131863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/24/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Despite its potential benefits, the utilization of stress-only protocol in clinical practice has been limited. We report utilizing stress-first single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). METHODS We assessed 12,472 patients who were referred for SPECT-MPI between 2013 and 2020. The temporal changes in frequency of stress-only imaging were assessed according to risk factors, mode of stress, prior coronary artery disease (CAD) history, left ventricular function, and symptom status. The clinical endpoint was all-cause mortality. RESULTS In our lab, stress/rest SPECT-MPI in place of rest/stress SPECT-MPI was first introduced in November 2011 and was performed more commonly than rest/stress imaging after 2013. Stress-only SPECT-MPI scanning has been performed in 30-34% of our SPECT-MPI studies since 2013 (i.e.. 31.7% in 2013 and 33.6% in 2020). During the study period, we routinely used two-position imaging (additional prone or upright imaging) to reduce attenuation and motion artifact and introduced SPECT/CT scanner in 2018. The rate of stress-only study remained consistent before and after implementing the SPECT/CT scanner. The frequency of stress-only imaging was 43% among patients without a history of prior CAD and 19% among those with a prior CAD history. Among patients undergoing treadmill exercise, the frequency of stress-only imaging was 48%, while 32% among patients undergoing pharmacologic stress test. In multivariate Cox analysis, there was no significant difference in mortality risk between stress-only and stress/rest protocols in patients with normal SPECT-MPI results (p = 0.271). CONCLUSION Implementation of a stress-first imaging protocol has consistently resulted in safe cancellation of 30% of rest SPECT-MPI studies.
Collapse
Affiliation(s)
- Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.
| | - Mark C Hyun
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Piotr J Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Damini Dey
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Alan Rozanski
- The Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| |
Collapse
|
2
|
McMahon SR, Patel EK, Duvall WL. Stress-First Myocardial Perfusion Imaging. Cardiol Clin 2023; 41:163-175. [PMID: 37003674 DOI: 10.1016/j.ccl.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Stress-first approaches to myocardial perfusion imaging provide diagnostically and prognostically accurate perfusion data equivalent to a full rest-stress study while saving time in the imaging laboratory and reducing the radiation exposure to patients and laboratory staff. Unfortunately, implementing a stress-first approach in a nuclear cardiology laboratory involves significant challenges such as the need for attenuation correction, triage of patients to an appropriate protocol, real-time review of stress images, and consideration of differential reimbursement. Despite it being best practice for both the patient and the laboratory, these impediments have kept the proportions of studies performed stress-first relatively unchanged in North America and world-wide in the last 10 years.
Collapse
Affiliation(s)
- Sean R McMahon
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - Etee K Patel
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - W Lane Duvall
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
| |
Collapse
|
3
|
Prediction of multivessel coronary artery disease and candidates for stress-only imaging using multivariable models with myocardial perfusion imaging. Ann Nucl Med 2022; 36:674-683. [PMID: 35661104 PMCID: PMC9226096 DOI: 10.1007/s12149-022-01751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 05/02/2022] [Indexed: 11/14/2022]
Abstract
Purpose Selecting patients with coronary multivessel disease (MVD) or no stenosis using myocardial perfusion imaging (MPI) is challenging. We aimed to create a model to predict MVD using a combination of quantitative MPI values and background factors of patients. We also assessed whether patients in the same database could be selected who do not require rest studies (stress-only imaging). Methods We analyzed data from 1001 patients who had been assessed by stress MPI at 12 centers and 463 patients who had not undergone revascularization in Japan. Quantitative values based on MPI were obtained using cardioREPO software, which included myocardial perfusion defect scores, left ventricular ejection fractions and volumes. Factors in MPI and clinical backgrounds that could predict MVD were investigated using univariate and multivariate analyses. We also investigated whether stress data alone could predict patients without coronary stenosis to identify candidates for stress-only imaging. Results We selected summed stress score (SSS), rest end-diastolic volume, and hypertension to create a predictive model for MVD. A logistic regression model was created with an area under the receiver operating characteristics curve (AUC) of 0.825. To more specifically predict coronary three-vessel disease, the AUC was 0.847 when SSS, diabetes, and hypertension were selected. The mean probabilities of abnormality based on the MVD prediction model were 12%, 24%, 40%, and 51% for no-, one-, two-, and three-vessel disease, respectively (p < 0.0001). For the model to select patients with stress-only imaging, the AUC was 0.78 when the model was created using SSS, stress end-systolic volume and the number of risk factors (diabetes, hypertension, chronic kidney disease, and a history of smoking). Conclusion A model analysis combining myocardial SPECT and clinical data can predict MVD, and can select patients for stress-only tests. Our models should prove useful for clinical applications.
Collapse
|
4
|
A Clinical Tool to Identify Candidates for Stress-First Myocardial Perfusion Imaging. JACC Cardiovasc Imaging 2020; 13:2193-2202. [PMID: 32563652 DOI: 10.1016/j.jcmg.2020.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study sought to develop a clinical model that identifies a lower-risk population for coronary artery disease that could benefit from stress-first myocardial perfusion imaging (MPI) protocols and that can be used at point of care to risk stratify patients. BACKGROUND There is an increasing interest in stress-first and stress-only imaging to reduce patient radiation exposure and improve patient workflow and experience. METHODS A secondary analysis was conducted on a single-center cohort of patients undergoing single-photon emission computed tomography (SPECT) and positron emission tomography (PET) studies. Normal MPI was defined by the absence of perfusion abnormalities and other ischemic markers and the presence of normal left ventricular wall motion and left ventricular ejection fraction. A model was derived using a cohort of 18,389 consecutive patients who underwent SPECT and was validated in a separate cohort of patients who underwent SPECT (n = 5,819), 1 internal cohort of patients who underwent PET (n=4,631), and 1 external PET cohort (n = 7,028). RESULTS Final models were made for men and women and consisted of 9 variables including age, smoking, hypertension, diabetes, dyslipidemia, typical angina, prior percutaneous coronary intervention, prior coronary artery bypass graft, and prior myocardial infarction. Patients with a score ≤1 were stratified as low risk. The model was robust with areas under the curve of 0.684 (95% confidence interval [CI]: 0.674 to 0.694) and 0.681 (95% CI: 0.666 to 0.696) in the derivation cohort, 0.745 (95% CI: 0.728 to 0.762) and 0.701 (95% CI: 0.673 to 0.728) in the SPECT validation cohort, 0.672 (95% CI: 0.649 to 0.696) and 0.686 (95% CI: 0.663 to 0.710) in the internal PET validation cohort, and 0.756 (95% CI: 0.740 to 0.772) and 0.737 (95% CI: 0.716 to 0.757) in the external PET validation cohort in men and women, respectively. Men and women who scored ≤1 had negative likelihood ratios of 0.48 and 0.52, respectively. CONCLUSIONS A novel model, based on easily obtained clinical variables, is proposed to identify patients with low probability of having abnormal MPI results. This point-of-care tool may be used to identify a population that might qualify for stress-first MPI protocols.
Collapse
|
5
|
Gowdar S, Chaudhry W, Ahlberg AW, Henzlova MJ, Duvall WL. Triage of patients for attenuation-corrected stress-first Tc-99m SPECT MPI using a simplified clinical pre-test scoring model. J Nucl Cardiol 2018; 25:1178-1187. [PMID: 28290100 DOI: 10.1007/s12350-017-0832-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 02/10/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stress-only Tc-99m SPECT MPI saves time and reduces radiation exposure while a normal study has a benign prognosis. However, no guidelines exist as to which patients should undergo stress-first MPI. The purpose of this study was to validate a previously published pre-test prediction scoring model and refine the stress-first triage process further if possible. METHODS We retrospectively reviewed all patients who underwent an attenuation-corrected Tc-99m SPECT MPI over a 39-month period. Based on 17-segment model semi-quantitative scoring, a successful stress-first MPI was defined as a summed stress attenuation-corrected score ≤ 1. Based on results from multivariate analysis, the previously published prediction score (comprised eight clinical and demographic variables) was compared to triage based on coronary artery disease (CAD) status alone and with the addition of other highly associated variables. Logistic regression and Chi-squared analyses were used to determine the magnitude of variable effect and to compare model results. RESULTS A total of 2,277 patients were included, and the prediction score successfully stratified patients into low-risk (91.1% successful stress-first), intermediate-risk (79.4%), and high-risk (50.7%) groups. Comparing the use of the prediction score to the use of a history of CAD as the only triage factor, 69.0% of patients would be accurately triaged using the prediction score with a cutoff of 7 (maximized sensitivity and specificity), while 78.6% were correctly triaged with CAD status alone (P < .0001). The addition of variables highly associated with a successful stress-first protocol (congestive heart failure [OR 3.4] and an abnormal resting ECG [OR 2.1]) to CAD status further enhanced triage accuracy to 81% (P < .0001). CONCLUSIONS While the previously described prediction score effectively identifies patients who can successfully undergo stress-first MPI, it is cumbersome. Triaging based solely on CAD status and with the addition of other key variables is practical and provides improved predictive accuracy for successful stress-first MPI. Utilizing this simplified pre-test scoring model may allow for wider adoption of stress-first imaging protocols which have clear advantages over traditional rest-stress protocols.
Collapse
Affiliation(s)
- Shreyas Gowdar
- Division of Cardiology, Heart and Vascular Institute, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Waseem Chaudhry
- Division of Cardiology, Maine Medical Center, Portland, ME, USA
| | - Alan W Ahlberg
- Division of Cardiology, Heart and Vascular Institute, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Milena J Henzlova
- Mount Sinai Division of Cardiology, Mount Sinai Heart, New York, NY, USA
| | - W Lane Duvall
- Division of Cardiology, Heart and Vascular Institute, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
| |
Collapse
|
6
|
Holly TA. Choosing patients for stress-first/stress-only imaging: Keep it simple. J Nucl Cardiol 2018; 25:1188-1190. [PMID: 28247263 DOI: 10.1007/s12350-017-0795-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Thomas A Holly
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| |
Collapse
|
7
|
Parker MW, Heller GV. Time to get on the stress-only bandwagon? J Nucl Cardiol 2018; 25:817-819. [PMID: 27743295 DOI: 10.1007/s12350-016-0691-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Matthew W Parker
- Division of Cardiovascular Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Gary V Heller
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA.
| |
Collapse
|
8
|
Gutstein A, Bental T, Solodky A, Mats I, Zafrir N. Prognosis of stress-only SPECT myocardial perfusion imaging with prone imaging. J Nucl Cardiol 2018; 25:809-816. [PMID: 27671493 DOI: 10.1007/s12350-016-0617-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stress-only single-photon emission computed tomography myocardial perfusion imaging (SO SPECT MPI) is associated with similarly benign prognosis as stress-rest SPECT MPI. However, previous studies have used attenuation correction rather than prone imaging to increase the rate of SO studies. OBJECTIVES To assess the prognosis of SO SPECT MPI performed with prone imaging. METHODS We performed a retrospective cohort analysis of all patients who underwent a Tc-99m gated SPECT MPI over a 58-month period. RESULTS Two thousand four hundred and sixty five patients were followed up. Of them, 1114 (45.2%) patients had a SO supine test, 388 (15.7%) underwent a SO supine and prone test, and the remaining 963 (39.1%) patients underwent a full stress-rest SPECT MPI. There was a similar annual mortality rate between the SO supine/prone group (1.3%), the SO supine (1.5%), and the stress-rest (1.5%) group (P = 0.47). Patients in the stress-rest group were significantly more likely to suffer from myocardial infarction (MI) as compared to the other two groups with an annual rate of 0.7% as compared to 0.4% (P = 0.049). CONCLUSIONS Normal supine-prone SO SPECT MPI is associated with a similarly benign prognosis as stress-rest SPECT MPI. The adjunction of prone imaging to the stress supine significantly increases the rate of SO SPECT MPI.
Collapse
Affiliation(s)
- Ariel Gutstein
- Rabin Medical Center, Tel-Aviv University, Petach Tikva, Israel.
| | - Tamir Bental
- Rabin Medical Center, Tel-Aviv University, Petach Tikva, Israel
| | | | - Israel Mats
- Rabin Medical Center, Tel-Aviv University, Petach Tikva, Israel
| | - Nili Zafrir
- Rabin Medical Center, Tel-Aviv University, Petach Tikva, Israel.
| |
Collapse
|
9
|
Gimelli A, Achenbach S, Buechel RR, Edvardsen T, Francone M, Gaemperli O, Hacker M, Hyafil F, Kaufmann PA, Lancellotti P, Nieman K, Pontone G, Pugliese F, Verberne HJ, Gutberlet M, Bax JJ, Neglia D, Gerber B, Donal E, Flachskampf F, Haugaa K, Delgado V, Knuuti J, Knaapen P, Maurovich-Horvat P, Schroeder S. Strategies for radiation dose reduction in nuclear cardiology and cardiac computed tomography imaging: a report from the European Association of Cardiovascular Imaging (EACVI), the Cardiovascular Committee of European Association of Nuclear Medicine (EANM), and the European Society of Cardiovascular Radiology (ESCR). Eur Heart J 2017; 39:286-296. [DOI: 10.1093/eurheartj/ehx582] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/26/2017] [Indexed: 12/23/2022] Open
Affiliation(s)
- Alessia Gimelli
- Fondazione Toscana/CNR Gabriele Monasterio, Via Moruzzi 1, 56124 Pisa, Italy
| | - Stephan Achenbach
- Department of Internal Medicine 2 (Cardiology), Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Thor Edvardsen
- Oslo University Hospital, Department of Cardiology, Rikshospitalet and University of Oslo, Oslo, Norway
| | - Marco Francone
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Oliver Gaemperli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Fabien Hyafil
- Department of Nuclear Medicine, Bichat University Hospital, Assistance Publique—Hôpitaux de Paris, Inserm 1148, DHU FIRE, University Paris 7 Diderot, Paris, France
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patrizio Lancellotti
- Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, University of Liège Hospital, GIGA Cardiovascular Sciences, Liège, Belgium
- Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - Koen Nieman
- Departments of Cardiovascular Medicine and Radiology, Stanford University, School of Medicine, Stanford, CA, USA
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Yonsei University Health System, Seoul, South Korea
| | - Francesca Pugliese
- NIHR Barts BRC, Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Jeroen J Bax
- Heart Lung Center Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Danilo Neglia
- Fondazione Toscana/CNR Gabriele Monasterio, Via Moruzzi 1, 56124 Pisa, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Stress-only myocardial perfusion scintigraphy: a prospective study on the accuracy and observer agreement with quantitative coronary angiography as the gold standard. Nucl Med Commun 2017; 38:904-911. [PMID: 28885540 DOI: 10.1097/mnm.0000000000000739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Patients with normal stress perfusion have an excellent prognosis. Prospective studies on the diagnostic accuracy of stress-only scans with contemporary, independent examinations as gold standards are lacking. PATIENTS AND METHODS A total of 109 patients with typical angina and no previous coronary artery disease underwent a 2-day stress (exercise)/rest, gated, and attenuation-corrected (AC), 99m-technetium-sestamibi perfusion study, followed by invasive coronary angiography. The stress datasets were evaluated twice by four physicians with two different training levels (expert and novice): familiar and unfamiliar with AC. The two experts also made a consensus reading of the integrated stress-rest datasets. The consensus reading and quantitative data from the invasive coronary angiography were applied as reference methods. RESULTS The sensitivity/specificity were 0.92-1.00/0.73-0.90 (reference: expert consensus reading), 0.93-0.96/0.63-0.82 (reference: ≥1 stenosis>70%), and 0.75-0.88/0.70-0.88 (reference: ≥1 stenosis>50%). The four readers showed a high and fairly equal sensitivity independent of their familiarity with AC. The expert familiar with AC had the highest specificity independent of the reference method. The intraobserver and interobserver agreements on the stress-only readings were good (readers without AC experience) to excellent (readers with AC experience). CONCLUSION AC stress-only images yielded a high sensitivity independent of the training level and experience with AC of the nuclear physician, whereas the specificity correlated positively with both. Interobserver and intraobserver agreements tended to be the best for physicians with AC experience.
Collapse
|
11
|
Slomka P, Hung GU, Germano G, Berman DS. Novel SPECT Technologies and Approaches in Cardiac Imaging. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016; 2:31-46. [PMID: 29034066 PMCID: PMC5640436 DOI: 10.15212/cvia.2016.0052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Recent novel approaches in myocardial perfusion single photon emission CT (SPECT) have been facilitated by new dedicated high-efficiency hardware with solid-state detectors and optimized collimators. New protocols include very low-dose (1 mSv) stress-only, two-position imaging to mitigate attenuation artifacts, and simultaneous dual-isotope imaging. Attenuation correction can be performed by specialized low-dose systems or by previously obtained CT coronary calcium scans. Hybrid protocols using CT angiography have been proposed. Image quality improvements have been demonstrated by novel reconstructions and motion correction. Fast SPECT acquisition facilitates dynamic flow and early function measurements. Image processing algorithms have become automated with virtually unsupervised extraction of quantitative imaging variables. This automation facilitates integration with clinical variables derived by machine learning to predict patient outcome or diagnosis. In this review, we describe new imaging protocols made possible by the new hardware developments. We also discuss several novel software approaches for the quantification and interpretation of myocardial perfusion SPECT scans.
Collapse
Affiliation(s)
- Piotr Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Guang-Uei Hung
- Department of Nuclear Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Guido Germano
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S. Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
12
|
Ben-Haim S, Kennedy J, Keidar Z. Novel Cadmium Zinc Telluride Devices for Myocardial Perfusion Imaging—Technological Aspects and Clinical Applications. Semin Nucl Med 2016; 46:273-85. [DOI: 10.1053/j.semnuclmed.2016.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
13
|
Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers. J Nucl Cardiol 2016; 23:606-39. [PMID: 26914678 DOI: 10.1007/s12350-015-0387-x] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | | | - Andrew J Einstein
- New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Mark I Travin
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | |
Collapse
|
14
|
Tamam M, Mulazimoglu M, Edis N, Ozpacaci T. The Value of Attenuation Correction in Hybrid Cardiac SPECT/CT on Inferior Wall According to Body Mass Index. World J Nucl Med 2016; 15:18-23. [PMID: 26912974 PMCID: PMC4729009 DOI: 10.4103/1450-1147.167586] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The purpose of this study was to evaluate the diagnostic value of attenuation-corrected single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) on the inferior wall compared to uncorrected (NC) SPECT MPI between obese and nonobese patients. A total of 157 consecutive patients (122 males and 35 females, with median age: 57.4 ± 11 years) who underwent AC technetium 99m-methoxyisobutylisonitrile (AC Tc99m-sestamibi) SPECT MPI were included to the study. A hybrid SPECT and transmission computed tomography (CT) system was used for the diagnosis with 1-day protocol, and stress imaging was performed first. During attenuation correction (AC) processing on a Xeleris Workstation using Myovation cardiac software with ordered subset expectation maximization (OSEM), iterative reconstruction with attenuation correction (IRAC) and NC images filtered back projection (FBP) were used. For statistical purposes, P < 0.05 was considered significant. This study included 73 patients with body mass index (BMI) <30 and 84 patients with BMI ≥ 30. In patients with higher BMI, increased amount of both visual and semiquantitative attenuation of the inferior wall was detected. IRAC reconstruction corrects the diaphragm attenuation of the inferior wall better than FBP. AC with OSEM iterative reconstruction significantly improves the diagnostic value of stress-only SPECT MPI in patients with normal weight and those who are obese, but the improvements are significantly greater in obese patients. Stress-only SPECT imaging with AC provides shorter and lower radiation exposure.
Collapse
Affiliation(s)
- Muge Tamam
- Department of Nuclear Medicine, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Mulazimoglu
- Department of Nuclear Medicine, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Nurcan Edis
- Department of Nuclear Medicine, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Tevfik Ozpacaci
- Department of Nuclear Medicine, Okmeydani Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
15
|
Marcassa C, Zoccarato O. Radiation Dose Reduction from Radionuclide Myocardial Perfusion Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-015-9364-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
16
|
Prognostic value of stress-only and stress-rest normal gated SPECT imaging: higher incidence of cardiac hard events in diabetic patients who underwent full stress-rest imaging. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015; 159:455-9. [DOI: 10.5507/bp.2014.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 05/07/2014] [Indexed: 11/23/2022] Open
|
17
|
Is Attenuation Correction for Myocardial Perfusion Imaging Underutilized? CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9346-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
18
|
Bateman TM. Twelfth annual Mario S. Verani, MD memorial lecture: Vision, leadership, and change-A reflection on the challenges and opportunities in the community-based practice of nuclear cardiology. J Nucl Cardiol 2015; 22:435-49. [PMID: 25894058 DOI: 10.1007/s12350-015-0126-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/09/2015] [Indexed: 12/23/2022]
|
19
|
Dorbala S, Blankstein R, Skali H, Park MA, Fantony J, Mauceri C, Semer J, Moore SC, Di Carli MF. Approaches to reducing radiation dose from radionuclide myocardial perfusion imaging. J Nucl Med 2015; 56:592-9. [PMID: 25766891 DOI: 10.2967/jnumed.112.115097] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 02/27/2015] [Indexed: 11/16/2022] Open
Abstract
Radionuclide myocardial perfusion imaging (MPI) plays a vital role in the evaluation and management of patients with coronary artery disease. However, because of a steep growth in MPI in the mid 2000s, concerns about inappropriate use of MPI and imaging-related radiation exposure increased. In response, the professional societies developed appropriate-use criteria for MPI. Simultaneously, novel technology, image-reconstruction software for traditional scanners, and dedicated cardiac scanners emerged and facilitated the performance of MPI with low-dose and ultra-low-dose radiotracers. This paper provides a practical approach to performing low-radiation-dose MPI using traditional and novel technologies.
Collapse
Affiliation(s)
- Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ron Blankstein
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hicham Skali
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mi-Ae Park
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jolene Fantony
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Charles Mauceri
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - James Semer
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephen C Moore
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marcelo F Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
20
|
Uretsky S, Cohen R, Argulian E, Balasundaram K, Supariwala A, Subero M, Sinha S, Paladugu K, DePuey EG, Rozanski A. Combining stress-only myocardial perfusion imaging with coronary calcium scanning as a new paradigm for initial patient work-up: an exploratory analysis. J Nucl Cardiol 2015; 22:89-97. [PMID: 25120131 DOI: 10.1007/s12350-014-9958-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/02/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND We conducted an exploratory analysis to test whether the addition of a CAC scan can increase the applicability of stress-only SPECT-MPI. METHODS We studied 162 patients referred for rest/stress SPECT-MPI who underwent a CAC scan. Each scan was interpreted by two readers in stepwise fashion: stress-only images; addition of clinical data; and addition of CAC data. At each step, the reader was asked if rest SPECT-MPI was necessary. RESULTS Stress-only images were interpreted as normal in 62, probably normal in 42, equivocal in 15, probably abnormal in 5, and definitely abnormal in 38 patients. Rest SPECT-MPI imaging was considered necessary, in 0% of normal studies, but in 88% of probably normal studies, and 100% of those with equivocal/abnormal studies. Addition of the clinical data did not materially change this decision. Additional consideration of the CAC scan results did not influence the deemed lack of need for a rest SPECT-MPI with normal SPECT-MPI or the necessity of rest SPECT-MPI with abnormal SPECT-MPI. However, the CAC scan reduced the deemed need for a rest SPECT-MPI in 72% with a probably normal, 47% with an equivocal, and 40% of those with a probably abnormal SPECT-MPI. CONCLUSIONS Our exploratory analysis indicates that addition of a CAC scan to stress SPECT-MPI tends to diminish experienced readers' deemed need to perform rest SPECT-MPI studies among patients with probably normal or borderline stress-only SPECT-MPI studies. Thus, further study appears warranted to assess the utility of using CAC scanning as a means for increasing the percent of SPECT-MPI studies that can be performed as stress-only studies.
Collapse
Affiliation(s)
- Seth Uretsky
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center, NJ,100 Madison Avenue, Morristown, NJ 07960, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Gowd BMP, Heller GV, Parker MW. Stress-only SPECT myocardial perfusion imaging: a review. J Nucl Cardiol 2014; 21:1200-12. [PMID: 25005348 DOI: 10.1007/s12350-014-9944-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 06/10/2014] [Indexed: 11/26/2022]
Abstract
Myocardial perfusion imaging (MPI) has enjoyed considerable success for decades due to its diagnostic accuracy and wealth of prognostic data. Despite this success several limitations such as lengthy protocols and radiation exposure remain. Advancements to address these shortcomings include abbreviated stress-only MPI (SO MPI) protocols, PET and both hardware and software methods to reduce radiation exposure and time. SO MPI has advantages in protocol time and radiation reduction with a wealth of supporting data in terms of diagnostic validity and prognostic value. Newer technologies such as attenuation correction, and advanced camera technologies have enabled SO MPI to be more efficient in reducing the time of acquisition and radiation dose and improving accuracy. This review examines the literature available, regarding accuracy, patient outcomes, implementation strategies, and newer developments associated with SO MPI.
Collapse
Affiliation(s)
- B M Pampana Gowd
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA,
| | | | | |
Collapse
|
22
|
Savvopoulos CA, Spyridonidis T, Papandrianos N, Vassilakos PJ, Alexopoulos D, Apostolopoulos DJ. CT-based attenuation correction in Tl-201 myocardial perfusion scintigraphy is less effective than non-corrected SPECT for risk stratification. J Nucl Cardiol 2014; 21:519-31. [PMID: 24532033 DOI: 10.1007/s12350-014-9867-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 01/25/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Previous studies advocate the use of attenuation correction in myocardial perfusion scintigraphy (MPS) for patient risk stratification. METHODS Six-hundred and thirty-seven unselected patients underwent Tl-201 MPS by a hybrid SPECT/CT system. Attenuation-corrected (AC) and non-corrected (NAC) images were interpreted blindly and summed stress scores (SSS) were calculated. Study endpoints were all-cause mortality and the composites of death/non-fatal acute myocardial infarction (AMI) and death/AMI/late revascularization. RESULTS During a follow-up of 42.3 ± 12.8 months 24 deaths, 13 AMIs and 28 revascularizations were recorded. SSS groups formed according to event rate distribution across SSS values were: 0-4, 5-13, >13 for NAC and 0-2, 3-9, >9 for AC. Kaplan-Meier functions were statistically significant between NAC SSS groups for all study endpoints. AC discriminated only between SSS 0-2 and >9 for death/AMI and between 0-2 and 3-9 for death/AMI/revascularization. In the univariate Cox regression abnormal NAC (SSS > 4) was accompanied with much higher hazards ratios than abnormal AC (SSS > 2). In the multivariate model abnormal AC yielded no significance for either endpoint whereas abnormal NAC proved independent from other covariates for the composite endpoints. CONCLUSION Our results challenge the effectiveness of CT-based AC for risk stratification of patients referred for MPS.
Collapse
Affiliation(s)
- Christos A Savvopoulos
- Department of Nuclear Medicine, University Hospital of Patras, University of Patras, Medical School, Rion, 26500, Patras, Greece
| | | | | | | | | | | |
Collapse
|
23
|
Ben-Haim S, Almukhailed O, Neill J, Slomka P, Allie R, Shiti D, Berman DS, Bomanji J. Clinical value of supine and upright myocardial perfusion imaging in obese patients using the D-SPECT camera. J Nucl Cardiol 2014; 21:478-85. [PMID: 24477404 DOI: 10.1007/s12350-014-9853-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 12/22/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE We have assessed whether additional upright imaging increases the confidence of interpretation of stress only supine myocardial perfusion imaging (MPI) in obese patients. METHODS AND RESULTS Tc-MIBI stress MPI of 101 consecutive patients (M = 49, 62 ± 12 years) with BMI ≥30 scanned on the D-SPECT cardiac camera were assessed. Images were interpreted as diagnostic or equivocal and the need for a rest study was recorded. Stress supine MPI was interpreted first, then gated and finally upright data were added. Defects on supine but not on upright were defined as artefacts and defects seen on both as abnormal. The total perfusion deficit (TPD) was also quantified. There were 27 normal, 22 abnormal, and 52 equivocal supine scans. The median EF was 52%, unaffecting the need for rest imaging. Upright imaging reclassified 32/52 (62%) equivocal studies as normal and 6/52 (11%) as abnormal (P < 0.001). Rest scan was deemed needed in 74/101 patients on supine vs 42/101 on supine/upright (P < 0.001). Supine TPD was normal in 53 and supine/upright TPD was normal in 70 patients (P < 0.001). CONCLUSION Supine stress MPI is inadequate in obese patients. The addition of upright imaging significantly increases the ability to interpret scans as diagnostic and may reduce considerably the need for rest imaging.
Collapse
Affiliation(s)
- Simona Ben-Haim
- Institute of Nuclear Medicine, University College London Hospitals, NHS Trust, London, UK,
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Duvall WL, Savino JA, Levine EJ, Baber U, Lin JT, Einstein AJ, Hermann LK, Henzlova MJ. A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department. J Nucl Cardiol 2014; 21:305-18. [PMID: 24310280 DOI: 10.1007/s12350-013-9823-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population. METHODS In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups. RESULTS A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P = .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P = .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P = .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort. CONCLUSIONS Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing.
Collapse
Affiliation(s)
- W Lane Duvall
- Mount Sinai Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, One Gustave L Levy Place, Box 1030, New York, NY, 10029, USA,
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Ardestani A, Ahlberg AW, Katten DM, Santilli K, Polk DM, Bateman TM, Heller GV. Risk stratification using line source attenuation correction with rest/stress Tc-99m sestamibi SPECT myocardial perfusion imaging. J Nucl Cardiol 2014; 21:118-26. [PMID: 24259152 DOI: 10.1007/s12350-013-9816-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 10/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although line source attenuation correction (AC) in SPECT MPI studies improves diagnostic accuracy, its prognostic value is less understood. METHODS Consecutive patients (n = 6,513) who underwent rest/stress AC ECG-gated SPECT MPI were followed for cardiac death or non-fatal myocardial infarction (MI). A 17-segment model and AC summed stress score (SSS) were used to classify images. RESULTS Of the 6,513 patients, cardiac death or non-fatal MI occurred in 267 (4.1%), over 2.0 ± 1.4 years. The AC-SSS in patients with a cardiac event (5.6 ± 7.8) was significantly higher than in those without (1.9 ± 4.6, P < .001). The annualized cardiac event rate in patients with an AC-SSS 1-3 (3.6%) was significantly higher than in those with an AC-SSS = 0 (1.1%, P < .001) but similar to that in those with an AC-SSS 4-8 (2.9%, P = .4). Accordingly, patients were classified to AC-SSS = 0, 1-8, and >8 with annualized cardiac event rates of 1.1%, 3.2%, and 8.5%, respectively (P < .0001). In multivariate analysis, an AC-SSS 1-8 and >8 emerged as independent predictors of cardiac events (P < .02 and P < .0001, respectively). CONCLUSION Rest/stress ECG-gated SPECT MPI with line source AC provides highly effective and incremental risk stratification for future cardiac events.
Collapse
Affiliation(s)
- Afrooz Ardestani
- Division of Cardiology, University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT, 06034, USA,
| | | | | | | | | | | | | |
Collapse
|
26
|
McMahon SR, Kikut J, Pinckney RG, Keating FK. Feasibility of stress only rubidium-82 PET myocardial perfusion imaging. J Nucl Cardiol 2013; 20:1069-75. [PMID: 23955287 DOI: 10.1007/s12350-013-9768-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Stress only SPECT myocardial perfusion imaging (MPI) is a validated strategy to streamline cardiac diagnostic imaging. The potential use of Rb82 PET stress only MPI has not been investigated. METHODS AND RESULTS Stress images from 200 Rb82 PET-MPI were reviewed by two blinded readers and categorized as not requiring additional rest images (normal) or requiring additional images (abnormal or equivocal). No additional images were deemed necessary for 95 (48%) and 99 (50%) by the two blinded readers. The stress only interpretation was compared to the previous read of the complete rest-stress study. The rate of detecting a normal result with stress only reading was 76%-79% with a negative predictive value of 94%-95%. Clinical predictors of a normal stress only PET-MPI included lower age, the absence of CAD, and female gender, but not body mass index. Blinded reads of 50 additional consecutive PET-MPI from patients with selected clinical predictors (age <65 years, no known CAD) were then performed. Of these, 40 (80%) were normal by previous rest-stress reading, and 34 (68%) were categorized as not requiring additional images after stress only reading. PET stress only imaging would have resulted in a mean reduction of radiation exposure of 2.4 mSv per study according to a published radiation estimate. CONCLUSION Stress only Rb82 PET-MPI is a feasible strategy to reduce resource utilization and radiation exposure associated with MPI. This strategy would be most applicable to patients with a lower pretest likelihood.
Collapse
Affiliation(s)
- Sean R McMahon
- Department of Medicine, Fletcher Allen Health Care, University of Vermont, 111 Colchester Avenue, Burlington, VT, 05401, USA,
| | | | | | | |
Collapse
|
27
|
Duvall WL, Levine EJ, Moonthungal S, Fardanesh M, Croft LB, Henzlova MJ. A hypothetical protocol for the provisional use of perfusion imaging with exercise stress testing. J Nucl Cardiol 2013; 20:739-47. [PMID: 23737159 DOI: 10.1007/s12350-013-9710-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 03/18/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous literature suggests that the results of myocardial perfusion imaging (MPI) add little to the prognosis of patients who exercise >10 metabolic equivalents (METS) during stress testing. With this in mind, we attempted to determine if a provisional injection protocol could be developed in which a patient would not receive an injection of radioisotope if adequate exercise was achieved without symptoms and a negative ECG response. This protocol would save a substantial amount of time, radiation exposure, and cost. METHODS All patients who underwent a stress SPECT MPI over a 6.5-year period from 2004 to 2010 were included. Patients who would have been considered for a standby injection protocol were: exercise stress, age < 65, no known coronary artery disease (CAD), and an interpretable ECG. Patients were retrospectively divided into two groups based on whether they would have received radioisotope or not. Criteria for not injecting included a maximal predicted heart rate ≥ 85%, ≥10 METS of exercise, no symptoms of chest pain or shortness of breath, and no ECG changes (ST depression or arrhythmia). The two groups were then compared based on MPI results and all-cause mortality derived from the Social Security Death Index. RESULTS A total of 24,689 patients underwent SPECT MPI during this period, and 5,352 would have been eligible for a provisional injection protocol. There were 3,791 (70.8%), who would have been injected and 1,561 (29.2%), who would not have been. Perfusion results were abnormal in 5.9% of non-injected group compared to 14.4% in those who would have been injected. After a mean follow-up of 60.6 ± 21.4 months, 1.1% had died in the non-injected cohort compared to 2.2% in the injected group. CONCLUSION A provisional injection protocol defined as age < 65, normal rest ECG, no history of CAD, and high level exercise with a negative ECG response and no symptoms has a very low 5-year all-cause mortality and low yield of MPI. If adopted it would decrease radiation exposure and save time and health care costs without jeopardizing prognosis.
Collapse
Affiliation(s)
- W Lane Duvall
- Mount Sinai Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, Box 1030, One Gustave L Levy Place, New York, NY, 10029, USA,
| | | | | | | | | | | |
Collapse
|
28
|
Multiple opportunities to reduce radiation dose from myocardial perfusion imaging. Eur J Nucl Med Mol Imaging 2013; 40:649-51. [PMID: 23407991 DOI: 10.1007/s00259-013-2355-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
29
|
Heller GV. Nuclear cardiology in the present and beyond: can we meet the challenges? J Nucl Cardiol 2013; 20:510-8. [PMID: 23709279 DOI: 10.1007/s12350-013-9727-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 04/29/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Gary V Heller
- University of Connecticut School of Medicine, Farmington, CT, USA.
| |
Collapse
|
30
|
Edenbrandt L, Ohlsson M, Trägårdh E. Prognosis of patients without perfusion defects with and without rest study in myocardial perfusion scintigraphy. EJNMMI Res 2013; 3:58. [PMID: 23902737 PMCID: PMC3733807 DOI: 10.1186/2191-219x-3-58] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 07/25/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stress myocardial perfusion scintigraphy (MPS) is widely regarded as a useful imaging modality for diagnosing patients with suspected ischemic heart disease. Current European guidelines recommend stress study to be performed first since rest study can be omitted if stress study is interpreted as normal. Thus, a rest study should only be performed in patients with equivocal or abnormal studies. The aim of the present study was to investigate the prognosis of a normal stress-only MPS compared to a normal stress-rest MPS in a retrospective manner and also with regard to normal/abnormal left ventricular function data. METHODS All 4,820 patients who underwent (99m)Tc MPS at Skåne University Hospital in Malmö, Sweden, in 2004 to 2007, for suspected or management of known ischemic heart disease were considered. The physician in clinical charge of the investigation decided whether a rest study was necessary or not. Based on the final report according to clinical routine, only patients with a normal perfusion study (no infarction or inducible ischemia) were included. The endpoints were non-fatal acute coronary syndrome or death from ischemic cardiac origin. RESULTS A total of 3,426 patients with a normal perfusion study were included. Of these, 2,215 patients had a stress-only study and 1,211 patients had both stress and rest studies. Mean follow-up was 6.2 years. The lowest event rate was found in the normal stress-only group (0.56% for normal stress-only patients vs. 1.42% for normal stress-rest patients; p < 0.0001). When dividing patients according to sex and stress type, the best prognosis was also found in the normal stress-only group (p < 0.0001 for all comparisons). Regarding left ventricular function data, we did not find any significant difference in event rate between normal vs. abnormal ejection fraction (EF), normal vs. abnormal end-diastolic volume (EDV) or normal EF, and EDV vs. abnormal EF or EDV for either the normal stress-only patients or the normal stress-rest patients. CONCLUSIONS Patients with a normal stress-only study had an excellent prognosis over a mean follow-up time of 6 years. Thus, omitting the rest study if the stress study is normal is a safe procedure.
Collapse
Affiliation(s)
- Lars Edenbrandt
- Clinical Physiology and Nuclear Medicine Unit, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Mattias Ohlsson
- Computational Biology and Biological Physics, Lund University, Lund, Sweden
| | - Elin Trägårdh
- Clinical Physiology and Nuclear Medicine Unit, Lund University, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
31
|
Prognosis of normal stress-only gated-SPECT myocardial perfusion imaging: a single center study. Int J Cardiovasc Imaging 2013; 29:1639-44. [DOI: 10.1007/s10554-013-0245-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 05/24/2013] [Indexed: 10/26/2022]
|
32
|
Duvall WL, Guma KA, Kamen J, Croft LB, Parides M, George T, Henzlova MJ. Reduction in Occupational and Patient Radiation Exposure from Myocardial Perfusion Imaging: Impact of Stress-Only Imaging and High-Efficiency SPECT Camera Technology. J Nucl Med 2013; 54:1251-7. [DOI: 10.2967/jnumed.112.112680] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
33
|
Harrison SD, Harrison MA, Duvall WL. Stress myocardial perfusion imaging in the emergency department--new techniques for speed and diagnostic accuracy. Curr Cardiol Rev 2013; 8:116-22. [PMID: 22708910 PMCID: PMC3406271 DOI: 10.2174/157340312801784916] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 08/20/2011] [Accepted: 09/05/2011] [Indexed: 11/22/2022] Open
Abstract
Emergency room evaluations of patients presenting with chest pain continue to rise, and these evaluations which often include cardiac imaging, are an increasing area of resource utilization in the current health system. Myocardial perfusion imaging from the emergency department remains a vital component of the diagnosis or exclusion of coronary artery disease as the etiology of chest pain. Recent advances in camera technology, and changes to the imaging protocols have allowed MPI to become a more efficient way of providing this diagnostic information. Compared with conventional SPECT, new high-efficiency CZT cameras provide a 3-5 fold increase in photon sensitivity, 1.65-fold improvement in energy resolution and a 1.7-2.5-fold increase in spatial resolution. With stress-only imaging, rest images are eliminated if stress images are normal, as they provide no additional prognostic or diagnostic value and cancelling the rest images would shorten the length of the test which is of particular importance to the ED population. The rapid but accurate triage of patients in an ED CPU is essential to their care, and stress-only imaging and new CZT cameras allow for shorter test time, lower radiation doses and lower costs while demonstrating good clinical outcomes. These changes to nuclear stress testing can allow for faster throughput of patients through the emergency department while providing a safe and efficient evaluation of chest pain.
Collapse
|
34
|
Henzlova MJ, Croft LB, Duvall WL. Stress-only imaging: faster, cheaper, less radiation. So what's the hold up? J Nucl Cardiol 2013; 20:17-9. [PMID: 23151754 DOI: 10.1007/s12350-012-9652-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
35
|
Mathur S, Heller GV, Bateman TM, Ruffin R, Yekta A, Katten D, Alluri N, Ahlberg AW. Clinical value of stress-only Tc-99m SPECT imaging: importance of attenuation correction. J Nucl Cardiol 2013; 20:27-37. [PMID: 23188624 DOI: 10.1007/s12350-012-9633-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND In selected patients, stress-only SPECT imaging has been proposed as an alternative to rest-stress SPECT imaging to improve laboratory efficiency and reduce radiation exposure. The impact of attenuation correction (AC) upon interpretation, post-test patient management and cardiac risk stratification in relation to stress-only imaging is not well understood. OBJECTIVES The purpose of this study was to determine the clinical value for laboratory throughput and predicting outcomes of normal and abnormal stress-only SPECT imaging with AC in a consecutive series of clinically referred patients. METHODS A retrospective analysis of 1,383 consecutive patients who were scheduled for stress-only SPECT imaging for symptom assessment of suspected myocardial ischemia was performed. All images had been interpreted and categorized using the standard 17-segment model without AC followed by AC. Follow-up data for 2.1 ± 1.3 years after SPECT imaging for the occurrence of cardiac events (non-fatal MI, cardiac death, and cardiac revascularization) previously collected by routine methods were reviewed. RESULTS Non-AC SPECT image interpretation revealed that 58% (802/1383) of patients had abnormal stress images. AC image interpretation of the abnormal non-AC images re-classified 83% (666/802) of these as normal. Among patients with abnormal stress images after AC (136/1383), 63% (86/136) returned for additional rest scans, while the remaining 37% (50/136) were clinically managed without further rest images. The incidence of cardiac death or non-fatal MI was very low in patients with normal stress-only scans (0.7%). CONCLUSION A strategy of stress-only imaging with AC in symptomatic patients is an efficient method which appropriately identifies at risk and low-risk patients yielding a low percentage requiring rest imaging. Clinical decisions can be made based on abnormal stress-only imaging without further rest imaging if clinically appropriate.
Collapse
Affiliation(s)
- Shishir Mathur
- Nuclear Cardiology Laboratory, Division of Cardiology, Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Cousins C, Miller DL, Bernardi G, Rehani MM, Schofield P, Vañó E, Einstein AJ, Geiger B, Heintz P, Padovani R, Sim KH. ICRP PUBLICATION 120: Radiological protection in cardiology. Ann ICRP 2013; 42:1-125. [PMID: 23141687 DOI: 10.1016/j.icrp.2012.09.001] [Citation(s) in RCA: 230] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Cardiac nuclear medicine, cardiac computed tomography (CT), interventional cardiology procedures, and electrophysiology procedures are increasing in number and account for an important share of patient radiation exposure in medicine. Complex percutaneous coronary interventions and cardiac electrophysiology procedures are associated with high radiation doses. These procedures can result in patient skin doses that are high enough to cause radiation injury and an increased risk of cancer. Treatment of congenital heart disease in children is of particular concern. Additionally, staff(1) in cardiac catheterisation laboratories may receive high doses of radiation if radiological protection tools are not used properly. The Commission provided recommendations for radiological protection during fluoroscopically guided interventions in Publication 85, for radiological protection in CT in Publications 87 and 102, and for training in radiological protection in Publication 113 (ICRP, 2000b,c, 2007a, 2009). This report is focused specifically on cardiology, and brings together information relevant to cardiology from the Commission's published documents. There is emphasis on those imaging procedures and interventions specific to cardiology. The material and recommendations in the current document have been updated to reflect the most recent recommendations of the Commission. This report provides guidance to assist the cardiologist with justification procedures and optimisation of protection in cardiac CT studies, cardiac nuclear medicine studies, and fluoroscopically guided cardiac interventions. It includes discussions of the biological effects of radiation, principles of radiological protection, protection of staff during fluoroscopically guided interventions, radiological protection training, and establishment of a quality assurance programme for cardiac imaging and intervention. As tissue injury, principally skin injury, is a risk for fluoroscopically guided interventions, particular attention is devoted to clinical examples of radiation-related skin injuries from cardiac interventions, methods to reduce patient radiation dose, training recommendations, and quality assurance programmes for interventional fluoroscopy.
Collapse
|
37
|
Ananthasubramaniam K, Bhatti S. Stress first myocardial perfusion imaging: is it time to put to rest the "rest first" strategy for most patients? J Nucl Cardiol 2012; 19:1106-9. [PMID: 22983811 DOI: 10.1007/s12350-012-9623-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 08/31/2012] [Indexed: 10/27/2022]
|
38
|
Duvall WL, Baber U, Levine EJ, Croft LB, Henzlova MJ. A model for the prediction of a successful stress-first Tc-99m SPECT MPI. J Nucl Cardiol 2012; 19:1124-34. [PMID: 23076554 DOI: 10.1007/s12350-012-9606-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 07/14/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Stress-only Tc-99m MPI saves time, radiation exposure, and a normal study has a benign prognosis. However, a stress-first protocol is relatively labor intensive requiring pre-test screening for suitability and early post-stress image review to determine the need for rest imaging. The purpose of this study was to develop a simple clinical score used prior to a patient's myocardial perfusion imaging (MPI) study to determine if they should undergo a stress-first protocol. METHODS We reviewed all patients who underwent Tc-99m SPECT MPI over a 27-month period and divided them into derivation and validation cohorts. Patients were categorized as having a successful stress-first protocol based on a summed stress score ≤1, with or without attenuation correction. We generated a multivariable model from the derivation cohort to identify demographic and clinical correlates of successful stress-first imaging. Two validation cohorts using a CZT and a conventional SPECT camera were then used to test the performance of the model. RESULTS The derivation cohort included 1,996 patients and the validation cohort consisted of 1,005 CZT SPECT patients and 2,430 conventional SPECT patients. The following variables were associated with unsuccessful (i.e., abnormal) stress-first imaging: age >65 years (1 point), diabetes (2 points), typical chest pain (2 points), congestive heart failure (3 points), abnormal ECG (4 points), male gender (4 points), and documented CAD (5 points). Emergency Department location (-2 points) was negatively associated with an unsuccessful protocol. An increasing score showed a strong association with an unsuccessful stress-first protocol in both the derivation and the validation cohorts (P < .0001) and dividing the cohorts into low (<5), intermediate (≥5 and <10), and high (≥10) risk scores accurately stratified patients based on their frequencies of unsuccessful stress-first imaging. ROC curve analysis showed excellent prediction in both the derivation and the validation cohorts with an area under the curve of 0.82 and 0.75-0.83, respectively. CONCLUSIONS This pre-test scoring tool accurately identifies patients who can successfully undergo a stress-first imaging protocol without the need for rest imaging and may allow for wider adoption of stress-first imaging protocols.
Collapse
Affiliation(s)
- W Lane Duvall
- Mount Sinai Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, P.O. Box 1030, One Gustave L Levy Place, New York, NY 10029, USA
| | | | | | | | | |
Collapse
|
39
|
Duvall WL, Hiensch RJ, Levine EJ, Croft LB, Henzlova MJ. The prognosis of a normal Tl-201 stress-only SPECT MPI study. J Nucl Cardiol 2012; 19:914-21. [PMID: 22814773 DOI: 10.1007/s12350-012-9601-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 07/02/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Stress-only Tc-99m SPECT myocardial perfusion imaging (MPI) decreases test time and patient radiation exposure with a proven benign prognosis of a normal study. The imaging sequence of Tl-201 MPI always starts with the stress portion; therefore, no pre-test decisions are needed regarding the imaging sequence. The recent intermittent Tc-99m shortage afforded the unique opportunity to study an unselected group of patients undergoing Tl-201 imaging. METHODS We retrospectively reviewed all the patients who had SPECT MPI with Tc-99m or Tl-201 over a 1-year period. When Tc-99m was not available, patients received Tl-201. All stress Tl-201 images were routinely processed, and if normal, rest imaging was not done. When Tc-99m was used, patients with lower pre-test probability were selected for a stress-first protocol. We compared the all-cause mortality of patients with normal Tl-201 studies to those with normal stress-only and rest-stress Tc-99m studies using the Social Security Death Index. Unadjusted and risk-adjusted survival analysis was performed. Specific causes of death (cardiac or non-cardiac) were determined by medical record review and contact with treating physicians. RESULTS A total of 3,658 patients underwent stress MPI during this time period. Of the 1,215 patients who had Tl-201 MPI, 716 (67%) had a normal stress-only study. Out of 2,443 patients who underwent Tc-99m MPI, 70% had normal perfusion with 1,098 normal stress-only studies and 493 normal rest-stress studies. The average follow-up was 23.3 ± 5.3 months. Unadjusted all-cause mortality at the end of follow-up was 7.1% in the Tl-201 stress-only group, 6.3% for Tc-99m stress-only patients, and 4.3% in the Tc-99m rest-stress cohort. After controlling for confounding variables, survival was similar in the three groups (HR 1.07, 95% CI 0.62-1.82, P = .82 for normal Tl-201 stress-only compared to normal Tc-99m rest-stress). The risk-adjusted 1-year survival was between 98.5 and 98.8% in the three groups. CONCLUSIONS Normal stress-only Tl-201 SPECT MPI study has a similarly benign prognosis when compared to Tc-99m rest-stress and Tc-99m stress-only normal SPECT MPI studies. The stress-first design allowed for early triage of over 60% of patients and marked improvement in laboratory efficiency due to shortened test time.
Collapse
Affiliation(s)
- W Lane Duvall
- Mount Sinai Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, PO Box 1030, One Gustave L Levy Place, New York, NY 10029, USA.
| | | | | | | | | |
Collapse
|
40
|
Shaw LJ, Hage FG, Berman DS, Hachamovitch R, Iskandrian A. Prognosis in the era of comparative effectiveness research: where is nuclear cardiology now and where should it be? J Nucl Cardiol 2012; 19:1026-43. [PMID: 22760523 DOI: 10.1007/s12350-012-9593-y] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Leslee J Shaw
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Room 529, Atlanta, GA 30324, USA.
| | | | | | | | | |
Collapse
|
41
|
DePuey EG, Ata P, Wray R, Friedman M. Very low-activity stress/high-activity rest, single-day myocardial perfusion SPECT with a conventional sodium iodide camera and wide beam reconstruction processing. J Nucl Cardiol 2012; 19:931-44. [PMID: 22777525 DOI: 10.1007/s12350-012-9596-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 06/19/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND A stress (S)/rest (R) 1-day Tc-99m sestamibi protocol is logistically advantageous and facilitates stress-only imaging. However, with conventional 370 MBq (10 mCi) S activity and subsequent 1,110-1,295 MBq (30-35 mCi) R activity there is a risk of S-to-R "shine-through" and underestimation of defect reversibility. New software methods cope with lower counting statistics and should allow for both a reduced S activity and also less likelihood of S-to-R "shine-through." METHODS 102 prospective patients [49 men, 53 women; mean weight 178 ± 41 lbs (range 98-265 lbs); chest 41.5″ ± 4.0″ (range 32″-52″)] received 192.4 + 18.5 MBq (5.2 ± 0.5 mCi) Tc-99m sestamibi S (25 exercise, 77 regadenoson) activity followed in 30-40 minutes by "full-time" (12 minutes) two-headed NaI camera S SPECT. Immediately thereafter, a 16-minute S SPECT acquisition was also performed in 37/102 patients. Then at 60-80 minute post-S all patients received 1328.3 + 129.5 MBq (35.9 ± 3.5 mCi) Tc-99m sestamibi, and "half-time" (7.5 minutes) R SPECT was acquired. All tomograms were processed with wide beam reconstruction (WBR, UltraSPECT Ltd.) software. A time-adjusted R/S myocardial count density ratio (MCDR) was calculated using automated software. S SPECT quality was visually graded (poor, fair, good, excellent) based upon myocardial definition, cavity contrast, RV visualization, and noise. For comparison, the S/R MCDR was calculated in 581 consecutive patients undergoing a conventional 370 MBq R/1110 MBq S (10 mCi R/30 mCi S) protocol. RESULTS S SPECT was normal in 44 patients (43%). Image quality was good-excellent in 93 (91%) patients with 12-minute S SPECT. Also in 37 (98%) patients with 16-minute S SPECT, quality was good-excellent. In patients with >42″ chests 12-minute S SPECT quality worsened with increasing chest circumference, manifested by myocardial "blurring." Image quality improved by ≥1 grade in the 12/37 patients (32%) also undergoing 16-minute S SPECT. The time- and decay-corrected 12-minute mean R/S MCDR was 5.78, a ratio adequate to minimize S-to-R shine-through, as verified in phantom experiments, and significantly better than a 3.79 S/R ratio achieved in the 581 patients undergoing a conventional R/S protocol. CONCLUSIONS An approximately 185 MBq (5 mCi S) Tc-99m SPECT processed with WBR provides adequate image quality. For larger patients prolonging image acquisition to 16 minutes is beneficial. For patients with normal S SPECT, a S-only protocol is feasible, affording them a very low (approximately 1.4 mSv) radiation dose. If subsequent R SPECT is necessary, it can be performed with approximately 1,332 MBq (36 mCi) with minimal S-R "shine-through."
Collapse
Affiliation(s)
- E Gordon DePuey
- St. Luke's-Roosevelt Hospital and Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | | | | | | |
Collapse
|
42
|
Depuey EG, Mahmarian JJ, Miller TD, Einstein AJ, Hansen CL, Holly TA, Miller EJ, Polk DM, Samuel Wann L. Patient-centered imaging. J Nucl Cardiol 2012; 19:185-215. [PMID: 22328324 DOI: 10.1007/s12350-012-9523-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
43
|
Techasith T, Cury RC. Stress myocardial CT perfusion: an update and future perspective. JACC Cardiovasc Imaging 2011; 4:905-16. [PMID: 21835384 DOI: 10.1016/j.jcmg.2011.04.017] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 03/31/2011] [Accepted: 04/07/2011] [Indexed: 10/17/2022]
Abstract
Coronary computed tomography angiography (CTA) has been shown by several multicenter trials to have excellent diagnostic accuracy in the detection and exclusion of significant coronary stenosis. However, a major limitation of coronary CTA is that the physiological significance of stenotic lesions identified is often unknown. Stress myocardial computed tomography perfusion (CTP) is a novel examination that provides both anatomic and physiological information (i.e., myocardial perfusion). Multiple single-center studies have established the feasibility of stress myocardial CTP. Furthermore, it has been illustrated that a combined CTA/CTP protocol improves the diagnostic accuracy to detect hemodynamic significant stenosis as compared with CTA alone; this combined protocol can also be accomplished at a radiation dose comparable to nuclear myocardial perfusion imaging exams. Although initial results hold some promise, stress myocardial CTP is a modality in its infancy. Further research is required to define, validate, and optimize this new technique. However, it is a modality with significant potential, particularly in the evaluation of chest pain patients, given the advantages of short exam time and comprehensive data acquisition. This review highlights how to perform and interpret stress myocardial CTP, summarizes the current literature, and discusses some future directions.
Collapse
|
44
|
|
45
|
Stress-only Tc-99m myocardial perfusion imaging in an emergency department chest pain unit. J Emerg Med 2011; 42:642-50. [PMID: 21875774 DOI: 10.1016/j.jemermed.2011.05.061] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 01/13/2011] [Accepted: 05/28/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND Stress-only myocardial perfusion imaging (MPI) saves time by eliminating rest imaging, which is important for emergency department (ED) throughput but has not been studied in an ED population. STUDY OBJECTIVE To determine the prognosis of a normal stress-only MPI study compared to a normal rest-stress MPI and establish its effectiveness in an ED setting. METHODS All patients evaluated in the ED over 6.5 years who underwent a stress-only technetium-99m gated MPI were compared to those who had a rest-stress study. All-cause mortality was determined using the Social Security Death Index. Survival was analyzed in patients with normal and abnormal MPI results. RESULTS A total of 4145 studies (2340 stress-only, 1805 rest-stress) were performed. Patients' average age was 57.9 years, 38.5% were male, and most had an intermediate or low pretest risk of coronary artery disease (87.7%). Average follow-up was 35.9 ± 20.9 months. In patients with normal perfusion, at 1 year of follow-up there were 11 deaths in the stress-only group (0.5% 1-year mortality), and 13 deaths in the rest-stress cohort (1.1% 1-year mortality). At the end of follow-up, the stress-only group had a lower all-cause mortality (p < 0.0001) and similar risk adjusted all-cause mortality (p = 0.10) than the rest-stress cohort. Patients with abnormal perfusion demonstrated the expected differential prognosis based on total perfusion deficits in both groups. CONCLUSIONS A normal stress-only MPI study has a benign 1-year prognosis similar to a rest-stress study when performed in the ED. The ability to triage patients more rapidly and reduce radiation exposure represents an attractive alternative for low-risk patients.
Collapse
|
46
|
Affiliation(s)
- Milena J Henzlova
- Mount Sinai Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, Box 1030, One Gustave L Levy Place, New York, NY 10029, USA.
| | | |
Collapse
|
47
|
Clinical usefulness of combinatorial protocol with stress only myocardial perfusion SPECT, CTA and SPECT/CTA 3-dimensional fusion image. Ann Nucl Med 2011; 25:387-95. [DOI: 10.1007/s12149-011-0476-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 01/24/2011] [Indexed: 10/18/2022]
|
48
|
Mahmarian JJ. Improving Efficiency in the Nuclear Cardiology Laboratory: The Role of Stress-Only Imaging Coupled with Faster Acquisition Protocols and New Stressor Agents. CURRENT CARDIOVASCULAR IMAGING REPORTS 2011. [DOI: 10.1007/s12410-011-9084-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
49
|
Pazhenkottil AP, Ghadri JR, Nkoulou RN, Wolfrum M, Buechel RR, Küest SM, Husmann L, Herzog BA, Gaemperli O, Kaufmann PA. Improved outcome prediction by SPECT myocardial perfusion imaging after CT attenuation correction. J Nucl Med 2011; 52:196-200. [PMID: 21270455 DOI: 10.2967/jnumed.110.080580] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED The aim of this study was to determine the impact of attenuation correction with CT (CT-AC) on the prognostic value of SPECT myocardial perfusion imaging (SPECT MPI). METHODS The summed stress score (SSS; 20-segment model) was obtained from filtered backprojection (FBP) and iterative reconstruction with CT-AC in 876 consecutive patients undergoing a 1-d stress-rest (99m)Tc-tetrofosmin SPECT MPI study for the evaluation of known or suspected coronary artery disease. Survival free of major adverse cardiac events (MACEs; cardiac death or nonfatal myocardial infarction) and survival free of any adverse cardiac events (including cardiac hospitalization, unstable angina, and late coronary revascularization) were analyzed by Kaplan-Meier analysis. RESULTS At a mean follow-up of 2.3 ± 0.6 y, a total of 184 adverse events occurred in 145 patients, including 35 MACEs (16 cardiac deaths [rate, 1.8%] and 19 nonfatal myocardial infarctions [rate, 2.2%]). With FBP, an SSS of 0-3 best distinguished patients with a low MACE rate (0.6%), followed by an SSS of 4-8 (4.3%), with increased MACE rate, and an SSS of 9-13 (3.8%), which was comparable. By contrast, with CT-AC the discrimination of low from intermediate MACE rate was best observed between an SSS of 0 (0%) and an SSS of 1-3 (3.7%), with a plateau at an SSS of 4-8 (3.2%). CONCLUSION CT-AC for SPECT MPI allows improved risk stratification. The prognostically relevant SSS cutoff is shifted toward lower values.
Collapse
|
50
|
Cerqueira MD, Allman KC, Ficaro EP, Hansen CL, Nichols KJ, Thompson RC, Van Decker WA, Yakovlevitch M. Recommendations for reducing radiation exposure in myocardial perfusion imaging. J Nucl Cardiol 2010; 17:709-18. [PMID: 20503120 DOI: 10.1007/s12350-010-9244-0] [Citation(s) in RCA: 242] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|