nuclear cardiology

1. Non Invasive testing of
myocardial ischemia
@IhabFathiSulima
2/11/2024

2. Out line
• Importance of ischemia testing. What we know.
• Rub 82 /FDG Cases discussion

3. When to test for myocardial ischemia
• Only test for ischemia if CP.
• ?? Preoperative
• Transplant work up e.g ESRD for renal TX
• Elderly and more than 2 Risk factors.

4. DIAD Study
• The authors conclude that screening for inducible
ischemia in asymptomatic patients with T2DM cannot
be advocated for 4 reasons:
• The yield of significant inducible ischemia is very low
• Overall cardiac event rates are low
• Routine screening does not appear to affect overall
outcome
• Routine screening would be prohibitively expensive
The much lower than expected event rates makes the
study inconclusive in demonstrating the lack of efficacy
of screening for subclinical CVD

5. 5
Figure 3. Top 10 Causes of Chest Pain in the ED Based on Age
(Weighted Percentage).
Created using data from Hsia RY, et
al. (3).

6. 6
Figure 5. Chest Pain and
Cardiac Testing
Considerations.
The choice of imaging depends on the clinical question of importance, to either a) ascertain the diagnosis of CAD and define coronary anatomy or b) assess
ischemia severity among patients with an expected higher likelihood of ischemia with an abnormal resting ECG or those incapable of performing maximal
exercise.
ACS indicates acute coronary syndrome; CAC, coronary artery calcium; CAD, coronary artery disease; and ECG, electrocardiogram.
Please refer to Section 4.1.
For risk assessment in acute chest pain: See Figure 9.
For risk assessment in stable chest pain: See Figure 11.

7. Two Categories
Ischemia category
• 1- Naïve Patients, Not Known cardiac.
• 2- Known Patients, labelled as Cardiac
Non ischemia category
• A. Endocarditis. FDG scan
• B. infiltrative disease Sarcoidosis FDG scan , amyloidosis Technetium PYP .
• C. Assess LV volumes or EF before or after chemotherapy. MUGA scan Rub 82
or FDG
12/29/2025 7
Indications for Nuclear testing
Who are They

9. Summary Estimates of Pooled Sensitivity and Specificity (with 95% confidence
intervals) for Non-Invasive Cardiac Tests for the Diagnosis of Coronary Artery Disease
Technology Sensitivity Specificity
Exercise Treadmill 0.68 (0.23-1.0) 0.77 (0.17-1.0)
Attenuation Corrected SPECT 0.86 (0.81-0.91) 0.82 (0.75-0.89)
Gated SPECT 0.84 (0.79-0.88) 0.78 (0.71-0.85)
Traditional SPECT 0.86 (0.84-0.88) 0.71 (0.67-0.76)
Contrast Stress Echocardiography (wall motion) 0.84 (0.79-0.90) 0.80 (0.73-0.87)
Exercise or Pharmacologic Stress Echocardiography 0.79 (0.77-0.82) 0.84 (0-.82-0.86)
Cardiac Computed Tomographic Angiography 0.96 (0.94-0.98) 0.82 (0.73-0.90)
Positron Emission Tomography 0.90 (0.88-0.92) 0.88 (0.85-0.91)
Cardiac MRI (perfusion) 0.91 (0.88-0.94) 0.81 (0.75-0.87)
Adapted from Gianrossi et al Circulation 1989; 80:87-98, Medical Advisory Secretariat 2010; 10:1-40,
and McArdle et al J Am Coll Cardiol 2012;60:1828-37

10. High Risk Features of Noninvasive Test Results Associated with
> 3% Annual Rate of Death or MI
Exercise Treadmill
• ≥ 2mm of ST-segment depression at low (< 5 metabolic equivalents, METS) workload or persisting
into recovery
• Exercise-induced ST-segment elevation
• Exercise-induced VT/VF
• Failure to increase systolic blood pressure to > 120 mm
Myocardial Perfusion Imaging
• Severe resting LV dysfunction (LVEF < 35%) not readily explained by non-coronary causes
• Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or
evidence of MI
• Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)
• Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores
indicating multiple vascular territories with abnormalities
• Stress-induced LV dilation
• Increased lung uptake
Stress Echocardiography
• Inducible wall motion abnormality involving >2 segments or 2 coronary beds
• Wall motion abnormality developing at low dose of dobutamine (< 10 micrograms/kg/min) or at a
low heart rate (<120 beats/min)
Coronary Computed Tomographic Angiography
• Multivessel obstructive CAD or left main stenosis on CCTA
Adapted from Fihn et al Circ 2012;126:e354-e471

11. Nuclear cardiology Report interpretation
I. Defects
 Location
 Extent
 Severity
 Reversible or fixed
 Quantitative or semi quantitative analysis
2. Other information
 Transient ischemic dilation
 Lung uptake
 RV during stress
 EF before and after stress 5-10% Increase
3. Other Un related Findings like masses 10% board

12. Cardiac stress test
Physical exercises
Exercise has to be adequate to produced the heterogenity in blood flow to achieve high
detection sensitivity
 Treadmil
 Ergocycle
Pharmacological
 Pharmacological stress test become important, since many patients are unable to exercise
 Pharmacological stress agents largely remove the need for patient cooperation and
motivation, and enable a confident assessment of cardiac function in virtually all cases
 Dipyridamole infusion
 Dobutamine infusion , be aware of arrhythmia, False positive in LBBB.
 Adenosine infusion
 Regadenoson more specific A2receptors. Bolus

13. Why not just use SPECT for
nuclear cardiology?
• SPECT diagnostic accuracy is good for some patients, but leaves
room for improvement
• Pharm stress studies are often difficult to read due to gut uptake1-2
• Obese and some female patients may have attenuation issues1-2
• Underestimation of extent & severity of CAD
• Tc-99m SPECT tracer kinetics are not proportional to blood flow, and have
extracardiac uptake1,3
• Limited detection of multi-vessel disease1,3
• Desire for Improved Efficiency
• 30 minutes with PET vs. 2.5 – 4 hours with SPECT1-2,4
1. Bateman, et. al. Journal of Nuclear Cardiology. 2006. 2. Merhige, et al. J
Nucl Med. 2007 3. Yoshinaga, et al. JACC. 2006. 4. Bateman Amer J Cardiol.
2004.

14. PET MPI Tracers
Tracer Half Life Dose Range Production
Method
Rb-82 75 sec 20–60 mCi Generator
N-13
Ammonia
9.8 min 7–20 mCi Cyclotron
O-15
Water
2.4 min 60–100 mCi Cyclotron
8. Nuclear Medicine Self-Study Program III: Nuclear Medicine Cardiology.
Botvinik, EH, Ed. 1998: Society of Nuclear Medicine, Reston, VA.

22. • A 56 years old male with prior Cardiac arrest Anterior STEMI on
18/11/2014 and alter on complicated left Cerebral (cardio embolic)
stroke. became wheelchaired with right side hemiparesis after the
incident.
• Heavy smoker, DLP and HTN.
• Had PPCI and Remained Stable.
• Recently Had Very Mild Atypical CP.
• PET/CT Rub82 Stress was arranged.

23. 18/11/2014
before
18/11/2014 after

28. 71 Years old lady with atypical chest pain

29. 63 years old lady with atypical chest Pain, was she fasting?

30. Old MI

34. • Calcified LV ANEURYSM
• ALVEOLAR EDEMA
• POOR LVEF
• GYNECOMASTIA

38. Journey of Hope

44. LEFT MAIN SPASM
SEVERE DLP

46. What is the extra cardiac finding ?

47. •Thank you