Nuclear imaging bck

B. C. Kansupada, MD, HeartCare Assoc. ACC chapter talk 4/28/06

B. C. Kansupada, MD HeartCare Assoc ACC chapter talk 4/28/06

Nuclear Imaging 2006Nuclear Imaging 2006
Bindu Kansupada, MD, MBA, FACC
HeartCare Associates
Member Payors Committee PACC

DisclosureDisclosure
Consultant/speaker bureau for:
 Medtronics
 Guident
 St. Judes
 Merck
 Bristol Myers Squib

Special Thanks:
Dr. Polk
Dr. Ronald Schwartz
Dr. Braunwald

Nuclear Cardiac ImagingNuclear Cardiac Imaging
(Myocardial Perfusion Imaging(Myocardial Perfusion Imaging))
Myocardial Perfusion Imaging – What is it?
MPI Images – What does it look like?
Clinical Value – What good is it?
Comparison with other modalities
 – Why MPI?

What is Myocardial PerfusionWhat is Myocardial Perfusion
Imaging?Imaging?
 In the U.S., nuclear cardiology (MPI) procedures have overtaken non-
cardiology procedures in procedural volume.
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
1994 1995 1996 1997 1998 1999 2000 2001 2002
Procedures(thousands)
Non-cardiology Cardiology Total

MPI is a non-invasive nuclear imaging
technique that uses radioactive imaging
agents to image the heart.
Thallium - 201
Technetium-99 m Sestamibi
Technetium-99 m Tetrofosmin
What is Myocardial PerfusionWhat is Myocardial Perfusion
Imaging?Imaging?

What do MPI images look like?What do MPI images look like?
 In a typical
nuclear cardiac
imaging exam, the
physician reviews:
– Static “Summed
Perfusion Images”
– Dynamic “Gated
Images”
Perfusion Images are viewed in three orientations:
SA – Short Axis
VLA – Vertical Long Axis
HLA - Horizontal Long Axis

What do MPI images look like? -What do MPI images look like? -
Summed Perfusion ImagesSummed Perfusion Images
Stress
Rest
Stress
Rest
Stress
Rest
Stress
Rest
SA
SA
VLA
HLA

What do MPI images look like? -
Summed Perfusion Images
• Summed images are used to assess cardiac perfusion. Rest and Stress
images are compared to determine if a region of the heart is “ischemic” –
starved of oxygen
• In the study below, the rest image indicates normal blood flow, but the stress
image indicates abnormal blood flow in the Inferior-lateral region.
• This may indicate “ischemia” in this region of the heart – which is supplied by
the LCX (left circumflex artery). There may be stenosis in that coronary artery.
Stress
Rest

What do MPI images look like?
Gated Images
• Gated images are made
possible by ECG-gated
SPECT
• Physicians can now
access cardiac function:
• Wall motion – does the
LV contract uniformly?
• Ejection Fraction – does
the LV pump out enough
blood to the body?
SA
HLA
VLA

What Good is MPI? – Clinical Value
• A nuclear stress test provides excellent negative predictive value
- Patients from the general population with normal MPI scans have <1%
annual risk of cardiac events

What Good is MPI? – Clinical Value
• A gated nuclear stress test is a powerful tool to risk stratify patients for
optimal management.
• It is in effect a “gate-keeper” to the cardiac cath lab

Coronary Distribution (Left Ventricle)Coronary Distribution (Left Ventricle)
Remember This
The 3 coronary arteries are:
LAD - left anterior descending artery
RCA - right coronary artery
LCX - left circumflex coronary artery

Type of NuclearType of Nuclear
ImagingImaging

Gated Study
Gating process-Functional assessment
ventricular wall motion
ES and ED ventricular volumes
LV ejection fraction
normal = 64% +/- 12%

Gated Study
Radiopharmaceutical
Tc-99m labeled red blood cells
in-vitro and in-vivo labeling
Images
anterior
left lateral
left anterior oblique (best LV
separation)

Gated Study
Exercise assessment
stress done with bicycle
rest EF to compare stress EF
Primary uses of test
congestive heart failure
cardiomyopathy
chemo cardiotoxicity

First Pass Cardiac Study
What’s ‘first pass’?
temporal separation of chambers
Functional assessment
ventricular wall motion
ES and ED ventricular volumes
LV and RV ejection fractions
pulmonary transit time

First Pass Cardiac Study
Can be performed with exercise
stress done with bicycle
rest EF to compare to stress EF
Primary uses of test
same as gated cardiac study
better than gated at right ventricle
assessment and cardiac shunts

Myocardial Perfusion Study
Assess coronary blood flow
Demonstrate blood perfusion of
the LV myocardium
Software allows gating for EF
3D reconstruction of heart

Myocardial Perfusion
Radiopharmaceuticals
Thallium-201 chloride
Tc-99m Sestamibi
Tc-99m Tetrofosmin
SPECT acquisition
provides cross-sectional images of the
myocardium in the short axis,
horizontal long axis and vertical long
axis planes

Performed at rest & stress
Stress study options
treadmill exercise
pharmacologic stress agents
adenosine
persantine (dipyridamole)
dobutamine

-Percentage of LV myocardium receiving
decreased perfusion
-Differentiate ischemia from MI
-24 hour delayed images demonstrate
myocardial viability (hibernating)
-Rest-only studies can provide information
on acute MI’s

Exam Results
Myocardial Infarction
perfusion defect on rest & stress
Myocardial Ischemia
perfusion defect on stress only

DiagnosticDiagnostic
ApproachApproach

Exercise ProtocolExercise Protocol
Exercise preferred modality
Radiopharmaceutical injected at peak and
continued exercise for another 1-2 minutes.
If unable to exercise, unable to attain target
heart rate, or contraindications
pharmacologic testing should be performed.
B-blockers should be held for 48 hours
No caffeine for 24 hours.

Exercise TestingExercise Testing-- ContraContra
IndicationsIndications
Unstable Angina
Decompensated CHF
Uncontrolled hypertension (blood pressure
> 200/115 mm of Hg)
Acute myocardial infarction within last 2 to
3 days
Severe pulmonary hypertension
Relative contraindication AS, HCM

Exercise TestingExercise Testing
Each of the protocols has advantages and
disadvantages.
Quality control from preparation,
acquisition to reading assure the best data.

Myocardial PerfusionScintigraphy:Myocardial PerfusionScintigraphy:
Assessment of Diagnosis, Prognosis, andAssessment of Diagnosis, Prognosis, and
Treatment Response of CardiovascularTreatment Response of Cardiovascular
Risk.Risk.
Diagnosis, Prognosis, and Response to
Therapy
Suspected Coronary artery disease
Known stable coronary artery disease
Prior to non-cardiac surgery
Before and after cardiac revascularization

Myocardial PerfusionScintigraphy:Myocardial PerfusionScintigraphy:
Assessment of Diagnosis, Prognosis, andAssessment of Diagnosis, Prognosis, and
Treatment Response of CardiovascularTreatment Response of Cardiovascular
RiskRisk
Diagnosis, Prognosis, and Response to
Therapy Special populations (women,
diabetics)
Evaluation of acute chest pain syndromes
Myocardial infarction
Screening: Multiple risk factors, Family
history
Response to medical therapy

Populations Who Benefit fromPopulations Who Benefit from
SPECT MPISPECT MPI
Diagnostic and prognostic chest pain evaluation
Angina
Atypical Angina
Atypical Chest Pain
Non-cardiac Chest Pain
Peri-operative risk of non-cardiac surgery
Diagnostic and prognostic evaluation of ACS
Emergency Department
In Hospital

Populations Who Benefit fromPopulations Who Benefit from
SPECT MPISPECT MPI
 Hemodynamic/prognostic assessment of known CAD
 High risk asymptomatic populatios
 Diabetes, Metabolic syndrome, insulin resistance syndrome
 Family history of sibling with coronary event
 Mediastinal radiation
 Multiple coronary risk factor
 Monitoring effectiveness of surgical and percutaneous
revascularization
 Monitoring effectiveness of “ medical revascularization”

120
2742 Men
1394 Women
+ MPI
+ EXERCISE
CLINICAL
Incremental Prognostic Value of MPI
Testing: Men vs. Women

Specificity of MPI with SPECT
Procedures in Women
P=.0004

Heart Disease in Women:Heart Disease in Women:
Lessons From The Past DecadeLessons From The Past Decade
The importance of studying gender specific aspects
of CAD have helped in the following clinical
dilemmas:
 Presentation of CAD: women are older than men
 Less Specific clinical manifestations of CAD in
women
 Greater Difficulty in Diagnosis: women>men
 More sever consequences of MI when it occurs in
women

Detecting CAD in WomenDetecting CAD in Women
 Evidence from numerous medical societies uniformly
supports association of exercise ECG has lower diagnostic
accuracy in women (more false positive)
 Critical Factors Affects Accuracy: Functional Capacity,
Rest ST-T changes, Hormonal Factors
 SPECT was better able to identify and satisfy women at
high risk for future events.
 Extent of total perfusion abnormality, extent of reversible
perfusion abnormality, multivessel abnormality, & large
perfusion abnormality are all strong predictors of future
cardiac events.
 Await RCT data from the WOMEN study to provide
further detail as to the value of SPECt in accessing risk in
women.

Long –Term outcome of PatientsLong –Term outcome of Patients
With Intermediate-Risk ExerciseWith Intermediate-Risk Exercise
Electrocardiograms who Do NotElectrocardiograms who Do Not
Have Myocardial Perfision DefectsHave Myocardial Perfision Defects
on Radionuclide Imagingon Radionuclide Imaging
Results
Cardiovascular survival was 99.8% at 1 year,
99.0% at 5 years and 98.5% at 7 years.
Near-normal scans and cardiac enlargement were
independent predictors of time to cardiac death.
Cardiac survival time free of myocardial infarction
or revascularization was 87.1% at 7 years.

Summary:Summary:
Acute Rest Imaging in 2005Acute Rest Imaging in 2005
 Strong predictor of short-term cardiac events
 Very high negative predictive value for acute MI
 Interpretative differences between acute and stress
imaging requires experience.
 Use in clinical decision-making and other acute
situations
 Consider as a gateway of opportunity to assess
intermediate to long term risk of patient -> value
of stress imaging following acute resting
evauation.

DIAD: Detection of Ischemia isDIAD: Detection of Ischemia is
Asymptomatic DiabetesAsymptomatic Diabetes
 Abnormalities were observed in:
- 22 % of patients with > 2 risk factors (66 of 306)
- 22 % of patients with < 2 risk factors (45 of 204)
Greater than one in five diabetic patients without
symptoms have an abnormal gated SPECT MPI
Selecting only patients who meet ADA guidelines
would have failed to identify 41 % of patients with
ischemia

Radionuclide MPS in Pre-Radionuclide MPS in Pre-
operative Risk Assessmentoperative Risk Assessment
 Perfusion imaging works so well in predicting outcome, we tend to
overuse it
 For patients with positive perfusion study, try to avoid
revascularization unless the patient needs it regardless of upcoming
surgery.
 Recent study demonstrates no benefit compared to beta blockade peri-
operatively.
 High risk subsets will benefit long term.
 Treat patients with mild reversible defects medically
 Avoid noncardiac surgery within 6 weeks of bare metal stenting
 Among patients who have CAD, or who are at risk of CAD, consider
preoperative beta blockade and statins.
 Several studies in clinical settings in which the ACC/AHA guidelines
were followed have demonstarted their effectiveness.

Shortcut to indications for noninvasive testing-Shortcut to indications for noninvasive testing-
Perform if any 2 of 3 factors are present.Perform if any 2 of 3 factors are present.
 High surgical risk operations
- AAA & PVD
- Long procedures with lg fluid shifts or blood loss
2. Poor functional capacity ( < 4 METs)
3. Intermediate clinical predictors presents
- CAD
>> Angina ( CCS I & II)
>> Prior MI
- CHF
- Diabetes or renal insufficiency.

Coronary Blood FlowCoronary Blood Flow
Myocardial blood flow reduction correlates
with degree of stenosis
Flow reserve reduces with coronary
stenoses of 45-50 %
Able to maintain resting flow untill stenosis
is 80-90 %

Coronary Blood Flow RatesCoronary Blood Flow Rates
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
mg/miin/g
Baseline Adeno Dipy Dobuta Exercise
Blood Flow

PrognosticPrognostic
Variables ofVariables of
Gated SPECTGated SPECT

Value of Stress MPI in theValue of Stress MPI in the
general population: Stress MPI:general population: Stress MPI:
Prognostic SignificancePrognostic Significance
0
1
2
3
4
5
6
7
8
Normal Abnormal
Nonfatal MI/Cardiac Death Rate Per Year ( Percent)
Nonfatal MI/Cardiac
Death Rate Per Year (
Percent)

Prognosis
•Prognostic data are incremental
•Normal scans: <1% cardiac event rate per
year
•Mildly abnormal scans:
–<1% cardiac death rate
–MI rate not affected by revascularization
–Treatment may be medical (catheterization
reserved for refractory symptoms)

Risk Stratification: PrognosisRisk Stratification: Prognosis
Risk of cardiac Death:
* Low
< 1 % per year
* Intermediate
1 – 3 % per year
* High
> 3 % per year

Risk Stratification: NoninvasiveRisk Stratification: Noninvasive
Testing MarkersTesting Markers
Amount of infarcted myocardium
Amount of jeopardized myocardium
Degree of jeopardy
Left vanticular systolic function
All can be assessed by measurements of
perfusion or function

TID: transit Ischemic DilationTID: transit Ischemic Dilation
(Stress induced LV Cavity(Stress induced LV Cavity
Dilation)Dilation)
 Severe, extensive CAD (usually with classic ischemic
defect)
Left Main
Prox LAD
MVD
 Microvascular disease (no stress defect; atypical defects)
HTN
LVH
DCM

Prognostic implications ofPrognostic implications of
myocardial perfusion imaging.myocardial perfusion imaging.

Single-photon emission computed tomographySingle-photon emission computed tomography
perfusion images in two patients with stableperfusion images in two patients with stable
anginal symptoms.anginal symptoms.

Incremental value Of SPECTIncremental value Of SPECT

Evaluation of CAD: A Prognostic Approach
Patients with suspected CAD referred to SPECT
Normal Study Mildly Abnormal Study Mod-Severely Abnormal Study
RISK OF ADVERSE EVENT
LOW INTERMEDIATE HIGH
Reassurance/Risk
factor modification
Aggressive risk factor
modification
Revascularization
Myocardial Perfusion Imaging with Gated SPECT

Evaluation of CAD:
A Diagnostic Approach
Patients with
possible CAD
Normal DIAGNOSTIC TES Abnormal
Low likelihood of CAD Intermediate to high
likelihood of CAD
Risk factor
modification
Revascularization

Cost EffectiveCost Effective
ApproachApproach

Myocardial perfusion imaging
•Cost effectiveness
•MPI as gatekeeper
•Incremental information

•High sensitivity
•Exclude disease
•Fewer false negatives
•Higher downstream costs in undiagnosed pts
•No need for 2nd
test vs. low sensitivity low cost
•High specificity
•Reduces number of false positive tests
•Reduced downstream testing
Principles of Cost-Effective Diagnosis
and Management of CAD using MPS

END Study: Financial Analysis of
Treatment Strategies
•11,249 consecutive stable angina patients
•Two treatment groups –Direct catheterization –Stress MPI
followed by selective catheterization
•Cohorts matched by pretest probability of CAD
•Strategy: cost minimization at equal mortality risk
•Cost evaluation –Diagnostic (early): SPECT, catheterization–
Follow-up (late): includes costs of PTCA, CABG Adapted from
Shaw LJ, et al.J Am CollCardiol. 1999;33:661-669. Cost-
effectiveness: Assessing the Prognostic Approach

END Study: Outcome by Screening Strategy

Pretest Clinical Risk (n=5,423) Pretest Clinical Risk (n=5,826)*
P <.01 vs catheterization.

Cost Effectiveness
in
Clinical Practice
•Patient risk assessed?
•Low risk, negative testing
•Intermediate risk, further testing
•If risk < 1% then no further
testing needed

Why to PracticeWhy to Practice
AppropriatenessAppropriateness
Criteria basedCriteria based
Practice?Practice?
One may not get reimbursed.One may not get reimbursed.
Inappropriate test could increase financialInappropriate test could increase financial
burden to society.burden to society.
Possible increased radiationPossible increased radiation

Appropriateness Criteria: SPECT MPIAppropriateness Criteria: SPECT MPI
 Tables 1 through 9 sequentially list the 52
indications by purpose, clinical scenario, and their
ratings, as obtained from the second-round rating
sheets. In addition, Tables 10 through 12 arrange
the indications into three main scoring categories
—those that were rated as inappropriate (I, me-
dian score of 1 to 3), uncertain or possibly
appropriate (U, median score of 4 to 6), and
appropriate (A, median score of 7 to 9),
respectively.

 Table 10 lists the 13 indications that were rated as
inappropriate (i.e., the imaging test is not
generally accept-able and is not a reasonable
approach for the indication). This does not
preclude, however, the performance of the test if
justifiable because of special clinical and patient
circumstances. It is likely that reimbursement
for the test will require a documented exception
from the physician.

Table 10. Inappropriate Indications (Median Rating of 1 to 3)
Indication
Appropriateness
Criteria
(Median Score)
Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome
1. ~ Low pre-test probability of CAD
~ ECG interpretable AND able to exercise
I (2.0)
Detection of CAD Symptomatic—Acute Chest Pain (in Reference to Rest Perfusion Imaging)
8.
~ High pre-test probability of CAD
~ ECG: ST elevation
I (1.0)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)
10. ~ Low CHD risk (Framingham risk criteria) I (1.0)
Risk Assessment: General and Specific Patient Populations—
Asymptomatic
17. ~ Low CHD risk (Framingham) I (1.0)

Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms—
Normal Prior SPECT MPI Study
21.
~ Normal initial RNI study
~ High CHD risk (Framingham)
~ Annual SPECT MPI study
I (3.0)
Abnormal Catheterization OR Prior SPECT MPI Study
23.
~ Known CAD on catheterization OR prior SPECT MPI
study in patients who have not had revascularization
procedure
~ Asymptomatic OR stable symptoms
~ Less than 1 year to evaluate worsening disease
I (2.5)
Risk Assessment With Prior Test Results: Asymptomatic—
Prior Coronary Calcium Agatston Score
28. ~ Agatston score less than 100 I (1.5)
Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—
Low-Risk Surgery
31. ~ Preoperative evaluation for non-cardiac surgery risk
assessment
I (1.0)

Intermediate-Risk Surgery
32.
~ Minor to intermediate perioperative risk predictor
~ Normal exercise tolerance (greater than or equal to 4 METS)
I (3.0)
Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—High Risk Surgery
36.
~ Asymptomatic up to 1 year post normal catheterization,
non-invasive test, or previous revascularization
I (3.0)
Risk
Assessment: Following Acute Coronary Syndrome STEMI—Hemodynamically
Signs of Cardiogenic Shock, or Mechanical Complications
Unstable,
38. ~ Thrombolytic therapy administered I (1.0)
Risk Assessment: Following Acute Coronary Syndrome—
Asymptomatic Post-Revascularization (PCI or CABG)
40. ~ Routine evaluation prior to hospital discharge I (1.0)
Risk Assessment: Post-Revascularization (PCI or CABG)—Asymptomatic
47. ~ Symptomatic prior to previous revascularization I (3.0)
~ Less than 1 year after PCI

Indication
Appropriatenes
s
Criteria
(Median Score)
Detection of CAD: Symptomatic—
Evaluation of Chest Pain Syndrome
3. ~ Intermediate pre-test probability of CAD A (7.0)
~ ECG uninterpretable OR unable to exercise
5. ~ High pre-test probability of CAD A (8.0)
6. ~ High pre-test probability of CAD A (9.0)
Acute Chest Pain (in Reference to Rest Perfusion Imaging)
7. ~ Intermediate pre-test probability of CAD
~ ECG: no ST elevation AND initial cardiac enzymes negative
A (9.0)
Table 11. Appropriate Indications (Median Rating of 7 to 9)

New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome
Detection of CAD: Asymptomatic—
New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction
Without Chest Pain Syndrome
12. ~ Moderate CHD risk (Framingham) A (7.5)
~ No prior CAD evaluation AND no planned cardiac
catheterization
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)—
New-Onset Atrial Fibrillation
15. ~ High CHD Risk (Framingham) A (8.0)
~ Part of the evaluation
Ventricular Tachycardia
16. ~ Moderate to high CHD risk (Framingham) A (9.0)

Asymptomatic
19. ~ Moderate to high CHD risk (Framingham)
A (8.0)
~ High-risk occupation (e.g., airline pilot)
20. ~ High CHD risk (Framingham) A (7.5)
Normal Prior SPECT MPI Study
22. ~ Normal initial RNI study
A (7.0)
~ High CHD risk (Framingham)
~ Repeat SPECT MPI study after 2 years or greater

Abnormal Catheterization or Prior SPECT MPI Study
24.
~ Known CAD on catheterization OR prior SPECT MPI study
in patients who have not had revascularization procedure
A (7.5)
~ Greater than or equal to 2 years to evaluate worsening disease
Risk Assessment With Prior Test Results: Worsening Symptoms—
Abnormal Catheterization OR Prior SPECT MPI Study
25. ~ Known CAD on catheterization OR prior SPECT MPI study A (9.0)

Indication
Appropriatenes
s
Criteria
(Median Score)
Prior Coronary Calcium Agatston Score
27. ~ Agatston score greater than or equal to 400 A (7.5)
Risk Assessment With Prior Test Results: UA/NSTEMI, STEMI, or
Chest Pain Syndrome—Coronary Angiogram
29. ~ Stenosis of unclear significance A (9.0)
Risk Assessment With Prior Test Results—
Duke Treadmill Score
30. ~ Intermediate Duke treadmill score
~ Intermediate CHD risk (Framingham)
A (9.0)
Intermediate-Risk Surgery
33.
~ Intermediate perioperative risk predictor OR
Poor exercise tolerance (less than 4 METS)
A (8.0)

High-Risk Surgery
35. ~ Minor perioperative risk predictor AND
A (8.0)
~ Poor exercise tolerance (less than 4 METS)
STEMI-Hemodynamically Stable
37.
~ Thrombolytic therapy administered
~ Not planning to undergo catheterization
A (8.0)
UA/NSTEMI—No Recurrent Ischemia OR No Signs of HF
39. ~ Not planning to undergo early catheterization A (8.5)
Risk Assessment: Post-Revascularization (PCI or CABG)—
Symptomatic
41. ~ Evaluation of chest pain syndrome A (8.0)

Asymptomatic
44. ~ Asymptomatic prior to previous revascularization
A (7.5)
~ Greater than or equal to 5 years after CABG
45. ~ Symptomatic prior to previous revascularization
A (7.5)
~ Greater than or equal to 5 years after CABG
Assessment of Viability/Ischemia: Ischemic Cardiomyopathy
(Includes SPECT Imaging for Wall Motion and Ventricular Function)
50.
~ Known CAD on catheterization
~ Patient eligible for revascularization
A (8.5)
Evaluation of Left Ventricular Function
51. ~ Non-diagnostic echocardiogram A (9.0)
Evaluation of Ventricular Function:
Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin)
52. ~ Baseline and serial measurements A (9.0)

Indication
Appropriateness
Criteria
(Median Score)
Evaluation of Chest Pain Syndrome
2.
~ Low pre-test probability of CAD
U* (6.5)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)
11. ~ Moderate CHD risk (Framingham) U (5.5)
Detection of CAD: Asymptomatic—
Valvular Heart Disease Without Chest Pain Syndrome
13.
~ Moderate CHD risk (Framingham)
~ To help guide decision for invasive studies
U (5.5)
Table 12. Uncertain Indications (Median Rating of 4 to 6)

New-Onset Atrial Fibrillation
14. ~ Low CHD risk (Framingham)
~ Part of the evaluation
U* (3.5)
Asymptomatic
18. ~ Moderate CHD risk (Framingham) U (4.0)
CT Coronary Angiography
26. ~ Stenosis of unclear significance U* (6.5)
High-Risk Surgery
34.
~ Minor perioperative risk predictor
~ Normal exercise tolerance (greater than or
equal to 4 METS)
U (4.0)

Asymptomatic
42.
~ Asymptomatic prior to previous
revascularization
~ Less than 5 years after CABG
U (6.0)
43.
~ Symptomatic prior to previous revascularization
~ Less than 5 years after CABG
U (4.5)
Asymptomatic
46.
revascularization
~ Less than 1 year after PCI
U* (6.5)
48.
revascularization
~ Greater than or equal to 2 years after PCI
U* (6.5)
49.
~ Symptomatic prior to previous revascularization
~ Greater than or equal to 2 years after PCI
U (5.5)

Summary:
Median Score 7 to 9 ---- Appropriate
Median Score 1 to 3 ---- Inappropriate
Median Score 4 to 6 ---- Uncertain

Pre-Cert Requirements in SE-PAPre-Cert Requirements in SE-PA
 IMPORTANT INFORMATION REGARDING
DIAGNOSTIC IMAGING SERVICES—NUCLEAR
CARDIOLOGY STUDIES
 INDEPENDENT BLUE CROSS HAS CONTRACTED
WITH AMERICAN IMAGING MANAGEMENT, INC
(AIM) TO IMPLEMENT A NEW RADIOLOGY
QUALITY INITIATIVE FOR OUTPATEINT NON-
EMERGENT DIAGNOSTIC IMAGING SERVICES
FOR NUCLEAR CARDIOLOGY.(KEYSTONE HPE,
PERSONAL CHOICE, AMERIHEALTH NJ, PPO
HMO)

 THE ORDERING PHYSICIAN IS TO
CONTACT AIM VIA NAVINET, PHONE OR
FAX, WHETHER THE ORDERING
PHYSICIAN IS A PCP OR A SPECIALIST.
 CALL CENTER TEL NUMBER IS—800-227-
3116
 FAX NUMBER IS—800-610-0050
 PROVIDERS MAY ACCESS AIM’S CLINICAL
GUIDELINES AND OTHER EDUCATIONAL
RESOURCES BY SELECTING THE AIM LINK
ON NAVINET OR BY ACCESSING AI’S
WEBSITE AT
WWW.AMERICANIMAGING.NET

FOR QUESTIONS REGARDING AIM
PROGRAM CALL CUSTOMER
SERVICE DEPARTMETN AT 800-252-
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
FOR CLAIM RELATED QUESTIONS
PLEASE CONTACT IBC PROVIDER
SERVICES DEPARTMENT –HMO CALL
215-567-3590 OR 800-227-3119/ FOR
PPO CALL 800-332-2566 OR YOUR
NETWORK COORDINATOR.

KEYSTONE MERCY—AETNA
THE ABOVE PLANS HAVE ENTERED
INTO AN ARRANGEMENT WITH
NATIONAL IMAGING ASSOCIATES
(NIA) FOR OUT PATEINT IMAGING
MANAGEMENT SERVICES.
CALL 800-642-7597—FOR AETNA
PRECERTIFICATON FOR NIA
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 CALL (866) 496-6200-FOR
PRECERTIFICATION-REMEMBER YOU
HAVE TO HAVE ANY OF THE
FOLLOWING CERTIFICATES ON FILE
WITH CARECORE Nuclear Certificates valid
from ONE OF the following (any one):

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Cardiology
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Cardiology
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 ABR—American Board of Radiology

 ALSO THE NUCLEAR FACILITY HAS TO
BE CERTIFIED BY CARECORE
GUIDELINES.

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