Nuclear imaging techniques have various applications in cardiology, including assessing coronary artery disease, left ventricular function, cardiomyopathy, valvular heart disease, cardiac shunts, pulmonary hypertension, and more. Myocardial perfusion imaging can accurately diagnose and assess the prognosis of coronary artery disease, viability after myocardial infarction, and effectiveness of revascularization procedures. Gated SPECT allows evaluation of both cardiac function and perfusion simultaneously. Other nuclear techniques help evaluate conditions like myocarditis, pulmonary embolism, and secondary causes of hypertension.

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. Applications of Nuclear Cardiology Coronary Artery Disease Assessment of LV /RV function Cardiomyopathy /Myocarditis Valvular Heart Disease Cardiac Shunts Secondary Hypertension Pulmonary Hypertension Assessment of Cardiac Transplant

3. Coronary Artery Disease Diagnosis of CAD Assessment of Prognosis Risk Stratification Stable /Unstable Angina Post MI Perioperative Diabetics Assessment of Myocardial Viability Assessment of Revascularization Procedure Acute chest pain management in ER

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. 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. Normal Scan

7. Visual scoring Score

8. LAD

9. Left Main

10. LCx

11. Multi Vessel Disease

12. CAD Assessment of Intervention

13. Post CABG Pre CABG

14. Pre PTCA Post PTCA

15. Coronary Artery Disease Assessment of Prognosis

16. Risk Stratification: Prognosis Low <1% per year Intermediate 1-3% per year High >3% per year Adapted from Gibbons RJ, et al. J Am Coll Cardiol. 1999;33:2092-2197. Risk of Cardiac Death: Normal MPI indicates good prognosis

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. High Risk Feature of SPECT MPI Following features demonstrate >3% annual mortality Post-stress EF <35% (99m-Technetium). Stress induced large perfusion defect. Stress induced multiple perfusion defects of moderate size. Large, fixed perfusion defect with LV dilation or increased lung uptake (Thallium-201). Stress induced moderate perfusion defect with LV dilation or increased lung uptake (Thallium 201). Gibbons et al. ACC/AHA/ACP-ASIM Chronic Stable Angina Guidelines. JACC . 1999.33: 2092-197.

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. High Risk Study

21. Low Risk Study Mild 3VD

22. Established Prognostic Role Prognostic role of perfusion imaging has documented accuracy of risk assessment in the following populations and conditions: CAD – suspected or known Angina – stable or unstable Women Diabetics Post-MI Post-revascularization Preoperative screening for noncardiac surgery

23. Coronary Artery Disease Acute Chest Pain Management in ER

24. Myocardial Scintigraphy for Acute Coronary Syndromes Onset of Symptoms Unclear Diagnosis Clinical Management Sestamibi injection Sestamibi SPECT One Hour

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. Infarct Imaging “ Hot Spot” Annexin V Perfusion Imaging THE LANCET • Vol 356 • July 15, 2000

27. Coronary Artery Disease Assessment of LV Function

28. Gated Myocardial Perfusion SPECT Courtesy of M Atiar Rahman, MD, of Ochsner Clinic. LA

29. Perfusion and Function Gated Myocardial Perfusion SPECT

30. LV Function

31. Blood pool gated SPECT

32. Assessment of Myocardial Viability Patients with CAD and LVF carry bad prognosis Patients with CAD and LVF have higher mortality during revascularization procedure Ischemic LVF patients can benefit from revascularization procedures if there is evidence of myocardial viability

33. Hibernating Myocardium

34. Scar Myocardium

35. Myocarditis Indium 111 Antimyosin AB Scan

36. Valvular Heart Disease Baseline and Exercise EF MUGA Scan Regurgitation Index (Stroke Volume Ratio) LV Stroke Counts – RV Stroke Counts Regurg Fraction = ______________________________ LV Stroke Counts LV Stroke Counts SVR = _____________________ RV Stroke Counts SVR >2 Moderately Severe Regurgitation SVR >3 Severe Regurgitation

37. Cardiac Transplant Assessment Indium-111 Imaging

38. Pulmonary Hypertension Pulmonary Embolism V/Q Scan Left to Right Shunt First Pass Study

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

41. Right to Left Shunt Body uptake of MAA > 6% of lung uptake

42. Secondary Hypertension Renal Artery Stenosis Captopril Renogram Study Pheochromocytoma I123 MIBG Scan

43. Pheochromocytoma I 123 MIBG Scan

44. Thank you for Listening