Nuclear Imaging In Cardiology Cme


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Role of Nuclear Imaging in the practice of cardiology

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  • For a patient with low pretest likelihood (10%), ECG testing can shift the posttest likelihood from 5% and 35% for a negative and positive test result, respectively. In contrast, nuclear testing can shift the posttest likelihood from 1% and 75% for a negative and positive test result, respectively. For patients with an intermediate pretest likelihood (50%), the ECG can shift posttest likelihood to 20% and 80% for negative and positive test results, respectively, while nuclear tests can shift posttest likelihood to 5% and 95%, respectively. For patients with a high pretest likelihood (90%), the ECG can shift posttest likelihood to 75% and 95% for negative and positive test results, respectively, while nuclear tests can shift posttest likelihood to 25% and 99%, respectively. The overall result is that both tests are more useful in the patient with intermediate likelihood of disease. In addition, the more accurate the test, the greater the shift in posttest likelihood, and the greater the clinical utility of the test.
  • The gated portion of the SPECT study allows both the visual and quantitative assessment of left ventricular function. These measures include left ventricular ejection fraction and end-diastolic and end-systolic volumes. In addition, this modality achieves excellent visualization of both the endocardial and epicardial surfaces, allowing for the evaluation of left ventricular wall motion and wall thickening. In this scan, the top row represents 3 short axis images (apical, mid, and basal short-axis slices) and the bottom row represents the mid, horizontal, and vertical long-axis slices.
  • Nuclear Imaging In Cardiology Cme

    1. 1. Nuclear Imaging in Cardiology Dr. Muhammad Ayub Diplomate Certification Board of Nuclear Cardiology Diplomate Certification Board of Cardiovascular CT Assistant Professor of Cardiology Punjab Institute of Cardiology, Lahore
    2. 2. Applications of Nuclear Cardiology <ul><li>Coronary Artery Disease </li></ul><ul><li>Assessment of LV /RV function </li></ul><ul><li>Cardiomyopathy /Myocarditis </li></ul><ul><li>Valvular Heart Disease </li></ul><ul><li>Cardiac Shunts </li></ul><ul><li>Secondary Hypertension </li></ul><ul><li>Pulmonary Hypertension </li></ul><ul><li>Assessment of Cardiac Transplant </li></ul>
    3. 3. Coronary Artery Disease <ul><li>Diagnosis of CAD </li></ul><ul><li>Assessment of Prognosis </li></ul><ul><li>Risk Stratification </li></ul><ul><ul><li>Stable /Unstable Angina </li></ul></ul><ul><ul><li>Post MI </li></ul></ul><ul><ul><li>Perioperative </li></ul></ul><ul><ul><li>Diabetics </li></ul></ul><ul><li>Assessment of Myocardial Viability </li></ul><ul><li>Assessment of Revascularization Procedure </li></ul><ul><li>Acute chest pain management in ER </li></ul>
    4. 4. Detection of CAD 68 81 92 89 87 0% 20% 40% 60% 80% 100% Sensitivity 77 87 84 90 89 Specificity Adapted from Beller GA Ex ECG (150 studies ) Stress echo (14 studies) Thallium SPECT (6 studies ) MIBI SPECT(3 studies) Tetrofosmin SPECT
    5. 5. Diagnostic Accuracy: Bayesian Analysis MPI Pretest ECG + + + 5% 35% 80% 20% 75% 95% 1% 75% 95% 5% 25% 99% Higher Sensitivity/Specificity Enhances Posttest Likelihood + + + Posttest Posttest 10% 90% 50%
    6. 6. Normal Scan
    7. 7. Visual scoring Score
    8. 8. LAD
    9. 9. Left Main
    10. 10. LCx
    11. 11. Multi Vessel Disease
    12. 12. CAD Assessment of Intervention
    13. 13. Post CABG Pre CABG
    14. 14. Pre PTCA Post PTCA
    15. 15. Coronary Artery Disease Assessment of Prognosis
    16. 16. Risk Stratification: Prognosis <ul><li>Low </li></ul><ul><li><1% per year </li></ul><ul><li>Intermediate </li></ul><ul><li>1-3% per year </li></ul><ul><li>High </li></ul><ul><li>>3% per year </li></ul>Adapted from Gibbons RJ, et al. J Am Coll Cardiol. 1999;33:2092-2197. Risk of Cardiac Death: Normal MPI indicates good prognosis
    17. 17. 5.1 7.4 25.0 33.5 33.7 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Clinical +Ex Clin +Ex +Cath Clin +Ex +SPECT All P =ns P <.01 P <.01 P =ns  2 Iskandrian AS, et al. J Am Coll Cardiol. 1993;22:665-670. Reproduced with permission. Copyright 1993 by the American College of Cardiology. N = 316 Incremental Prognostic Value NS=not significant
    18. 18. High Risk Feature of SPECT MPI <ul><li>Following features demonstrate >3% annual mortality </li></ul><ul><ul><li>Post-stress EF <35% (99m-Technetium). </li></ul></ul><ul><ul><li>Stress induced large perfusion defect. </li></ul></ul><ul><ul><li>Stress induced multiple perfusion defects of moderate size. </li></ul></ul><ul><ul><li>Large, fixed perfusion defect with LV dilation or increased lung uptake (Thallium-201). </li></ul></ul><ul><ul><li>Stress induced moderate perfusion defect with LV dilation or increased lung uptake (Thallium 201). </li></ul></ul>Gibbons et al. ACC/AHA/ACP-ASIM Chronic Stable Angina Guidelines. JACC . 1999.33: 2092-197.
    19. 19. Patients with Suspected CAD Anti-anginal Therapy Aggressive RFM Cath if symptoms refractory to therapy A Risk-based Approach to Suspected CAD Cardiac Cath RFM Mod-Severely Abnormal Intermediate to high risk for cardiac death or MI Reassurance Risk factor (RFM) modification Normal Very low risk for cardiac death, Low risk for MI Mildly Abnormal Low risk for cardiac death, Intermediate risk for MI Tc-99 Myocardial Perfusion with Gated SPECT
    20. 20. High Risk Study
    21. 21. Low Risk Study Mild 3VD
    22. 22. Established Prognostic Role <ul><ul><ul><li>Prognostic role of perfusion imaging has documented accuracy of risk assessment in the following populations and conditions: </li></ul></ul></ul><ul><ul><ul><ul><li>CAD – suspected or known </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Angina – stable or unstable </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Women </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diabetics </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Post-MI </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Post-revascularization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Preoperative screening for noncardiac surgery </li></ul></ul></ul></ul>
    23. 23. Coronary Artery Disease Acute Chest Pain Management in ER
    24. 24. Myocardial Scintigraphy for Acute Coronary Syndromes Onset of Symptoms Unclear Diagnosis Clinical Management Sestamibi injection Sestamibi SPECT One Hour
    25. 25. Abn NI Chest Pain + Non-diagnostic ECG) Abn NI 2 hours NI Abn NI Abn 13 hours 3 sets Patients with Abnormal Tests are Admitted Rest SPECT Immediate Ex ECG Ex ECG Enzymes
    26. 26. Infarct Imaging “ Hot Spot” Annexin V Perfusion Imaging THE LANCET • Vol 356 • July 15, 2000
    27. 27. Coronary Artery Disease Assessment of LV Function
    28. 28. Gated Myocardial Perfusion SPECT Courtesy of M Atiar Rahman, MD, of Ochsner Clinic. LA
    29. 29. Perfusion and Function Gated Myocardial Perfusion SPECT
    30. 30. LV Function
    31. 31. Blood pool gated SPECT
    32. 32. Assessment of Myocardial Viability <ul><li>Patients with CAD and LVF carry bad prognosis </li></ul><ul><li>Patients with CAD and LVF have higher mortality during revascularization procedure </li></ul><ul><li>Ischemic LVF patients can benefit from revascularization procedures if there is evidence of myocardial viability </li></ul>
    33. 33. Hibernating Myocardium
    34. 34. Scar Myocardium
    35. 35. Myocarditis Indium 111 Antimyosin AB Scan
    36. 36. Valvular Heart Disease <ul><li>Baseline and Exercise EF MUGA Scan </li></ul><ul><li>Regurgitation Index (Stroke Volume Ratio) </li></ul><ul><li> LV Stroke Counts – RV Stroke Counts </li></ul><ul><li>Regurg Fraction = ______________________________ </li></ul><ul><li> LV Stroke Counts </li></ul><ul><li> LV Stroke Counts </li></ul><ul><li>SVR = _____________________ </li></ul><ul><li> RV Stroke Counts </li></ul><ul><ul><li>SVR >2 Moderately Severe Regurgitation </li></ul></ul><ul><ul><li>SVR >3 Severe Regurgitation </li></ul></ul>
    37. 37. Cardiac Transplant Assessment Indium-111 Imaging
    38. 38. Pulmonary Hypertension Pulmonary Embolism V/Q Scan Left to Right Shunt First Pass Study
    39. 40. Normal First Pass Study Left to Right Shunt Qp/Qs= 2.6 A ratio of less than 1.5 indicates a small left-to-right shunt. A ratio of 2.0 or more indicates a large left-to-right shunt
    40. 41. Right to Left Shunt Body uptake of MAA > 6% of lung uptake
    41. 42. Secondary Hypertension Renal Artery Stenosis Captopril Renogram Study Pheochromocytoma I123 MIBG Scan
    42. 43. Pheochromocytoma I 123 MIBG Scan
    43. 44. Thank you for Listening
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