This document summarizes nuclear quality assurance cases from August to October 2009 and discusses trends and ways to improve reporting. There was one major discordance in August that was likely a minor discordance due to imaging quality issues. In September and October, most cases were in agreement with catheterization findings, though two cases in October were minor discordances. The document highlights issues with physician reports such as lack of details on planar findings and inconsistencies in stating risk. Overall trends in 2009 showed improvement in nuclear-catheterization correlation, though more poor quality studies were seen in late 2009.

1. Nuclear QA: Case
Review
Darcy Conaway
January 2010

2. OUTLINE
• CASES FROM AUGUST, SEPTEMBER, AND
OCTOBER 2009
• TRENDS
• DISCUSSION OF WAYS TO IMPROVE
REPORTING

3. About Nuclear QA
• Keepcath of all patients that had a nuclear followed
by a
log
within a year
• Do the findings correlate?
• COMPLETE AGREEMENT
• GENERAL AGREEMENT
• MINOR DISCORDANCE
• MAJOR DISCORDANCE

4. Nuke QA Started in 2008
• Initial problems primarily due to very high false
positive rate causing high major discordance rates
• We initiated prone imaging, using regadenoson,
became diligent with patient selection (ex: 2-day
studies for elevated BMI) and adopted the ASNC
recommended method for reporting
• 2009 trends showed improvement

5. **Significant percentages of major
discordances when comparing nuclear to
cardiac catheterization
--July 2008: 5 major discordances (71%)
7 total for correlation
--August 2008: 1 major discordance (20%)
5 total for correlation
--September 2008: 3 major discordances
(50%)
6 total for correlation

6. -cont.
October 2008: 5 major discordances (36%)
14 total for correlation
November 2008: No major discordances
(0%)
14 total for correlation
December 2008: 1 major discordance (17%)
6 total for correlation

7. Trends January 2009-May 2009
• January 2009: No major discordances (4 total for
correlation0%
• February 2009: 2 major discordances (8 total for
review; 1 of these was deemed appropriately read and due
to quality of imaging by case review)13%
• March 2009: No nuclear/cath for correlation
• April 2009: 0 major discordance (5 total for
review0%)
• May 2009: 1 major discordance that is due to patchy
uptake in a cardiomyopathy patient (4 total for correlation)
• June 2009: No major discordances
• July 2009: 1/6 major discordance (17%)

8. Trends and Case Review
8/09-10/09
• AUGUST 2009: 78 total nukes done
• 3 for correlation with cath
• 1 major discordance….WOULD LIKE
INPUT AS TO WHETHER OR NOT THIS IS
A MAJOR DISCORDANCE

9. • MPI 2/3/09 CASE 1
• CATH 8/28/09
• 1-DAY STUDY
• REGADENOSON
• PRONE USED AS AN
ADJUNCT
• ECG NEGATIVE
• POST STRESS
IMAGING 45 MINUTES
AFTER INJECTION

10. SHORT AXIS SUPINE SHORT AXIS PRONE

11. LONG AXIS SUPINE LONG AXIS PRONE

12. POLARMAPS

13. REMINDER: PRONE

14. MPI IMPRESSION
• NEGATIVE ECG FOR ISCHEMIA
• NORMAL EF
• NORMAL PERFUSION

15. CATH
• LM normal
• LAD 40% proximal, 40-50% mid to distal
• diag 2 30%
• LCx 70% distally, small artery
• RCA (dominant) subtotal occlusion proximal with left
to right collaterals
• unsuccessful angioplasty; small self contained
coronary perforation

16. NUKE MISREAD OR MISSED ISCHEMIA?
• LABELLED AS A FALSE NEGATIVE BUT I THINK THIS
IS LIKELY A MINOR DISCORDANCE
• DISTAL LCX IS SMALL; MAY BE MILDLY ISCHEMIC
BUT THE QUALITY OF THE REST IMAGES ARE
PROBLEMATIC IN READING THIS STUDY
ACCURATELY
• COLLATERALS TO THE RCA WOULD PREVENT IT
FROM BEING ISCHEMIC AND ECG WAS NEGATIVE
• ONE POINT: SHOULD ATTEMPT PRONE OF REST
WHEN DEFECT PRESENT
• CONCERN: DID WE PERFORM PROCEDURE
CORRECTLY/I.E. MAXIMAL HYPEREMIA WITH
REGADENOSON? ECG NEGATIVE ...
FALSE NEGATIVE? MINOR DISCORDANCE?
NOT GETTING MAXIMAL HYPEREMIA
WITH REGADENOSON?

17. CORRELATION
• SEPTEMBER (N=85)
• 12 FOR CORRELATION; 1 EXCLUDED
DUE TO BEING >1 YEAR FROM NUKE
TO CATH
• 1 MAJOR DISCORDANCE THAT WAS
LIKELY BALANCED ISCHEMIA
(‘ACCEPTABLE FALSE NEGATIVE’)

18. -CONT
• OCTOBER (N=60); 11 TO CORRELATE
• 8/11 WERE CA OR GA
• 13 TOTAL: 1 NON-DIAGNOSTIC, 1
EXCLUDED DUE TO BEING JUST AT A
YEAR OUT FROM CATH
• 2 MINOR DISCORDANCES
• 1 UNKNOWN: MPI NO ISCHEMIA;
CATH WITH LAD BRIDGING.
GENERAL AGREE?

19. CASE 2: SHORT AXIS SUPINE
• MPI 8/4/09
• ONE DAY STUDY
• REGADENOSON
• PRONE USED AS AN
ADJUNCT
• NEGATIVE ECG
• STRESS IMAGING 48MIN
AFTER ISOTOPE
• REST IMAGING 45 MIN
AFTER

20. SHORT AXIS SUPINE SHORT AXIS PRONE

21. LONG AXIS SUPINE LONG AXIS PRONE

23. MPI IMPRESSION
• MILDLY ABNORMAL (SSS6) WITH FIXED
INFERIOR/INFEROLATERAL DEFECT
• QUALITY:FAIR
• EF NORMAL WITH MILD INFERIOR/
INFEROLATERAL HYPOKINESIS

24. CATH
• LM normal
• LAD ostial 60%
• LCx free of disease
• RCA free of disease
• Ramus free of disease
CASE OF SIGNIFICANT ARTIFACT
THAT LED TO MISREAD
PLANAR: ELEVATED LEFT MINOR
HEMIDIAPHRAGM DISCORDANCE?
FAIR QUALITY

25. CASE 3
• 2-DAY STUDY
• EXERCISE (6:32)
• MALE PT
• STRESS IMAGING 2
HOURS AFTER
INJECTION; REST
IMAGING 40 MINUTES
AFTER INJECTION

26. SHORT AXIS SUPINE SHORT AXIS PRONE

27. LONG AXIS SUPINE LONG AXIS PRONE

28. POLARMAPS

29. REVIEW: PRONE

30. MPI IMPRESSION
• MILDLY ABNORMAL; SUGGESTIVE OF
BRANCH VESSEL LAD DISEASE
(DIAGONAL)
• TECHNICAL ISSUES WITH GATING SO
NO EF GIVEN

31. CATH
• NORMAL CORONARIES
• MPI PLANAR WITH MILD BREAST
ATTENUATION, LATERAL WALL FAT
AND MILD VERTICAL MOTION
MINOR DISCORDANCE?
MORE SIGNIFICANT?

32. CASE 4
• 1-DAY STUDY
• REGADENOSON
• PRONE USED AS AN
ADJUNCT
• REST: 1HR AND 15 MIN
AFTER INJECTION
• STRESS:1 HOUR AND 5
MINUTES AFTER

33. SHORT AXIS SUPINE SHORT AXIS PRONE

34. LONG AXIS SUPINE LONG AXIS PRONE

35. POLARMAPS

36. MPI IMPRESSION
• OCCLUDED LCX AND/OR RCA
BRANCH VESSEL AT BASE WITHOUT
ISCHEMIA
• LOW RISK
• MILDLY REDUCED EF

37. CATH
• NON OBSTRUCTIVE CAD
THIS IS DOWN AS A
GENERAL AGREEMENT
SINCE IT WAS READ AS
LOW RISK; CHANGE TO
DISCORDANCE?

38. NEXT CASE
• 45 Y/O MALE WITH KNOWN CAD/PRIOR MI
• EXERCISE STUDY (7:46)
• ECG WITH T WAVE INVERSION AT BASELINE
INFEROLATERALLY; PSEUDONORMALIZATION
DURING STRESS
• 1-DAY STUDY WITH PRONE AS
ADJUNCT

39. CASE 5
SUPINE PRONE

42. MPI
IMPRESSION
• ABNORMAL WITH LARGE FIXED INFERIOR
DEFECT AND MODERATE FIXED ANTERIOR
DEFECT
• DO YOU AGREE ? THOUGHTS....
• NORMAL EF
• POOR QUALITY
• Prior nuke in 2003 with large defect, also non-

43. CATH-the plot thickens
• The one we correlated with was 10/09:
• No significant CAD; mid-distal focal area
of myocardial bridging LAD
• Prior cath in 2005:
• 90% proximal ramus intermedius
• 50-60% proximal rca
SO IS THIS THE
WRONG CATH?

44. NEXT CASE: GOOD
CORRELATION DESPITE
ATTENUATION
• 39 Y/O FEMALE
• 2-DAY STUDY DUE TO BMI
• REGADENOSON (??)
• SEVERE BREAST ATTENUATION
• PRONE USED AS ADJUNCT
• SHOULD WE HAVE DONE NUKE?

45. CASE 6
SHORT AXIS SHORT AXIS
SUPINE PRONE

46. LONG AXIS
LONG AXIS PRONE
SUPINE

47. POLARMAPS

48. MPI IMPRESSION
• POOR QUALITY: SEVERE BREAST
ATTENUATION
• MODERATE AREA OF INFARCTION
INFERIOR AND INFEROLATERALLY
SUGGESTING RCA AND/OR LCX
DISEASE
• NORMAL EF

49. CATH
• TWO VESSEL CAD
• RCA MID 90%, MID-DISTAL 70%
• MID LAD 60% (NEGATIVE FFR OF LAD)

50. NEXT CASE
• 56Y/O MALE WITH PPM
• REGADENOSON
• 1-DAY STUDY WITH PRONE AS
ADJUNCT

51. SHORT AXIS SUPINE SHORT AXIS PRONE

52. potter 2

53. MPI IMPRESSION AND CATH
• MPI: RCA OR LCX INFARCTION WITH
MINIMAL RESIDUAL ISCHEMIA ; LOW
RISK
• CATH: 3 VESSEL CAD
• 70-80% PROX LAD, 99% OSTIAL LCX,
80% MID RCA LIKELY A CASE OF BALANCED
ISCHEMIA WITH TIGHTER LCX SO
ONLY ONE DISTRIBUTION
DEMONSTRATED ISCHEMIA; MAJOR
DISCORDANCE THAT IS
“ACCEPTABLE?”

54. NEXT CASE
• 58Y/O FEMALE
• EXERCISE STUDY (6:20)
• 1-STUDY STUDY
• PLANAR FINDINGS NOT MENTIONED-
QUALITY LISTED AS FAIR (LIKELY
BREAST ATTENUATION)
• PRONE USED AS ADJUNCT

55. SHORT AXIS SUPINE SHORT AXIS PRONE

56. wright 5

57. CORRELATION
• MPI: ABNORMAL; POSITIVE FOR ISCHEMIA
• NO MENTION OF RISK OF STUDY
• ANTERIOR DEFECT FELT TO BE DUE TO BREAST;
MODERATE REVERSIBLE DEFECT APICALLY AND LATERALLY
• CATH: LAD PCI; MILD TO MODERATE LCX (NO
PERCENTAGE GIVEN), PLV OSTIUM (SMALL VESSEL) WITH
90% FOCAL STENOSIS
FOR QA: GENERAL AGREE? SOME COMMENT SHOULD BE MADE
THAT NUKE NOT GOOD FOR THIS PT IN THE FUTURE DUE TO
SEVERITY OF BREAST ATTENUATION? PLACE IT INTO NON-
DIAGNOSTIC FOR LAD TERRITORY?

58. NOVEMBER/DECEMBER
• HIGH NUMBERS OF POOR QUALITY STUDIES
• NOVEMBER: (N=80);14 FOR CORRELATION
• 7/14 WERE IN GENERAL OR COMPLETE AGREEMENT
• 2 MINOR DISCORDANCE-->PLANAR FINDINGS NOT DESCRIBED ON EITHER OF
THESE
• 3 MAJOR DISCORDANCE--> 1 LIKELY BALANCED ISCHEMIA (‘ACCEPTABLE’ MAJOR
DISCORDANCE); ANOTHER DESCRIBED AS POOR QUALITY BUT NOT READ AS
NON-DIAGNOSTIC; OTHER NEEDS REVIEW
• 1 NON-DIAGNOSTIC DUE TO BREAST ATTENUATION
• ISSUE: IF POOR QUALITY STUDY WE SHOULD STATE WHY IN PLANAR SECTION AND
READ STUDY AS NON-DIAGNOSTIC

59. • DECEMBER (N=59); 14 FOR CORRELATION
• 7/14 CA OR GA
• I MINOR DISCORDANCE
• 2 MAJOR DISCORDANCE; 1 DOCUMENTED AS
POOR QUALITY STUDY
• 1 READ AS NON-DIAGNOSTIC DUE TO BREAST,
1 READ AS EQUIVOCAL DUE TO SEVERE
VERTICAL MOTION, 1 TECHNICAL ISSUE (FAIR

60. REPORTING ISSUES
• MANY STUDIES WITHOUT MENTION OF
PLANAR IMAGING FINDINGS
• NEED TO STATE IF PRONE WAS OR WAS NOT
PERFORMED
• MUST HAVE CORONARY ARTERY DISTRIBUTION
FOR DEFECTS--MANY STUDIES REPORTED ONLY
AS ISCHEMIC WITHOUT MENTION OF
DISTRIBUTION OR SEVERITY OF RISK (MILD/
MOD/SEVERE)

61. REVIEW
• OVERALL TREND FOR 2009 WAS
SIGNIFICANT IMPROVEMENT
• THE LAST TWO MONTHS THERE WERE
INCREASED NUMBERS OF POOR
QUALITY IMAGES (PT SELECTION?)
• PHYSICIAN REPORTS: LACKING
PLANAR IMAGING FINDINGS AND
CONSISTENCY IN TERMS OF STATING
RISK

62. REMINDER: ASNC GUIDELINES
FOR REPORTING
• REQUIRED: PERFUSION DEFECT LOCATION,
SEVERITY, AND SIZE
• SEVERITY= MILD,MODERATE,SEVERE
• SMALL= 1-2 SEGMENTS
• MEDIUM=3-4 SEGMENTS
• LARGE= 5 OR MORE SEGMENTS
• TID IS REQUIRED

63. TO THINK ABOUT...
• MANY EXPERTS BELIEVE THAT AC IMAGING CAN
INCREASE THE NUMBER OF STRESS ONLY
IMAGES (GETTING ASKED MORE FREQUENTLY
TO DO THIS WHEN POSSIBLE ON IN-PTS)
• REMINDER: THIS IS APPLICABLE MAINLY TO PTS
WHO EXERCISE
• PHARMACOLOGIC NORMALS HAVE
SIGNIFICANTLY HIGHER RATE OF CARDIAC
EVENTS WITHIN THE NEXT YEAR AS
COMPARED TO NORMALS WHO DID BRUCE