Nuclear ImagingNuclear Imagingin Cardiologyin Cardiology

Dr. Muhammad AyubDr. Muhammad AyubDiplomate Certification Board of Nuclear CardiologyDiplomate Certification Board of Nuclear Cardiology

Diplomate Certification Board of Cardiovascular CTDiplomate Certification Board of Cardiovascular CT

Assistant Professor of CardiologyAssistant Professor of Cardiology

Punjab Institute of Cardiology, LahorePunjab Institute of Cardiology, Lahore

Applications of Nuclear Applications of Nuclear CardiologyCardiology

Coronary Artery DiseaseCoronary Artery Disease Assessment of LV /RV functionAssessment of LV /RV function Cardiomyopathy /MyocarditisCardiomyopathy /Myocarditis Valvular Heart DiseaseValvular Heart Disease Cardiac ShuntsCardiac Shunts Secondary HypertensionSecondary Hypertension Pulmonary HypertensionPulmonary Hypertension Assessment of Cardiac TransplantAssessment of Cardiac Transplant

Coronary Artery DiseaseCoronary Artery Disease Diagnosis of CADDiagnosis of CAD Assessment of Prognosis Assessment of Prognosis Risk StratificationRisk Stratification

Stable /Unstable AnginaStable /Unstable Angina Post MIPost MI PerioperativePerioperative DiabeticsDiabetics

Assessment of Myocardial ViabilityAssessment of Myocardial Viability Assessment of Revascularization ProcedureAssessment of Revascularization Procedure Acute chest pain management in ERAcute chest pain management in ER

Detection of CAD

68

81

92 89 87

0%

20%

40%

60%

80%

100%

Sensitivity

77

87 8490 89

Specificity

Ex ECG (150 studies) Stress echo (14 studies)Thallium SPECT (6 studies) MIBI SPECT(3 studies)Tetrofosmin SPECT

Adapted from Beller GA

Diagnostic Accuracy: Bayesian Diagnostic Accuracy: Bayesian AnalysisAnalysis

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%

Normal ScanNormal Scan

Visual scoringVisual scoring

1

0

4

2

4

4

1

2

2

3

4

4

100%

70

50

30

10

0

4 normal 100 - 70%

3 mild 70 - 50%

2 moderate 50 - 30%

1 severe 30 - 10%

0 absent 10 - 0%

Score

LADLAD

Left MainLeft Main

LCxLCx

Multi Vessel DiseaseMulti Vessel Disease

CADCAD

Assessment of InterventionAssessment of Intervention

Post CABG

Pre CABG

Pre Pre PTCAPTCA

Post PTCAPost PTCA

Coronary Artery DiseaseCoronary Artery Disease

Assessment of Assessment of PrognosisPrognosis

Risk Stratification: Risk Stratification: PrognosisPrognosis

Low Low <1% per year<1% per year

Intermediate Intermediate

1-3% per year1-3% per year High High

>3% per year>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 prognosisNormal MPI indicates good prognosis

5.17.4

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 Incremental Prognostic ValueValue

NS=not significant

High Risk Feature of SPECT High Risk Feature of SPECT MPIMPI

Following features demonstrate >3% Following features demonstrate >3% annual mortalityannual mortality Post-stress EF <35% (99m-Technetium).Post-stress EF <35% (99m-Technetium). Stress induced large perfusion defect.Stress induced large perfusion defect. Stress induced multiple perfusion defects of Stress induced multiple perfusion defects of

moderate size.moderate size. Large, fixed perfusion defect with LV dilation or Large, fixed perfusion defect with LV dilation or

increased lung uptake (Thallium-201).increased lung uptake (Thallium-201). Stress induced moderate perfusion defect with Stress induced moderate perfusion defect with

LV dilation or increased lung uptake (Thallium LV dilation or increased lung uptake (Thallium 201).201).

Gibbons et al. ACC/AHA/ACP-ASIM Chronic Stable Angina Guidelines. JACC. 1999.33: 2092-197.

Patients with Suspected CAD

Anti-anginal TherapyAggressive RFM

Cath if symptoms refractory to therapy

A Risk-based Approach to A Risk-based Approach to Suspected CADSuspected CAD

Cardiac CathRFM

Mod-Severely Abnormal Intermediate to high

risk for cardiac death or MI

ReassuranceRisk factor (RFM)

modification

NormalVery low risk

for cardiac death, Low risk for MI

Mildly AbnormalLow risk for cardiac death, Intermediate

risk for MI

Tc-99 Myocardial Perfusion with Gated SPECT

High Risk StudyHigh Risk Study

Low Risk Study Low Risk Study Mild 3VDMild 3VD

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

Coronary Artery Coronary Artery DiseaseDiseaseAcute Chest Pain Acute Chest Pain

Management in ERManagement in ER

Myocardial Scintigraphy for Acute Coronary Syndromes

Onset of Symptoms

UnclearDiagnosis

Clinical Management

Sestamibi injection Sestamibi SPECT

One Hour

AbAbnn

AbAbnn

NINININI

Chest PainChest PainChest PainChest Pain + Non-diagnostic + Non-diagnostic ECG)ECG)+ Non-diagnostic + Non-diagnostic ECG)ECG)

Rest Rest SPECTSPECTRest Rest

SPECTSPECT

AbAbnn

AbAbnn

NINININI

ImmediateImmediateEx ECGEx ECG

ImmediateImmediateEx ECGEx ECG

2 h

ours

2 h

ours

2 h

ours

2 h

ou

rs

NINININI AbAbnn

AbAbnn

Ex ECGEx ECGEx ECGEx ECG

NINININI AbAbnn

AbAbnn

13 h

ou

rs1

3 h

ou

rs1

3 h

ou

rs1

3 h

ou

rs

3 sets3 sets3 sets3 sets

EnzymesEnzymesEnzymesEnzymes

Patients with Abnormal Tests are Admitted

Infarct Imaging Infarct Imaging

“Hot Spot” Annexin V Perfusion Imaging

THE LANCET • Vol 356 • July 15, 2000

Coronary Artery Coronary Artery DiseaseDisease

Assessment of LV FunctionAssessment of LV Function

Gated Myocardial Perfusion SPECT

Courtesy of M Atiar Rahman, MD, of Ochsner Clinic. LA

Perfusion and FunctionGated Myocardial Perfusion SPECT

LV FunctionLV Function

Blood pool gated SPECT

Assessment of Myocardial Assessment of Myocardial ViabilityViability

Patients with CAD and LVF carry bad Patients with CAD and LVF carry bad prognosisprognosis

Patients with CAD and LVF have Patients with CAD and LVF have higher mortality during higher mortality during revascularization procedurerevascularization procedure

Ischemic LVF patients can benefit Ischemic LVF patients can benefit from revascularization procedures if from revascularization procedures if there is evidence of myocardial there is evidence of myocardial viability viability

Hibernating MyocardiumHibernating Myocardium

Scar MyocardiumScar Myocardium

MyocarditisMyocarditisIndium 111 Antimyosin AB ScanIndium 111 Antimyosin AB Scan

Valvular Heart DiseaseValvular Heart Disease Baseline and Exercise EF Baseline and Exercise EF MUGA ScanMUGA Scan Regurgitation Index (Stroke Volume Ratio)Regurgitation Index (Stroke Volume Ratio)

LV Stroke Counts – RV Stroke CountsRegurg Fraction = ______________________________

LV Stroke Counts

LV Stroke Counts SVR = _____________________ RV Stroke Counts

SVR >2SVR >2Moderately Severe RegurgitationModerately Severe Regurgitation SVR >3SVR >3Severe RegurgitationSevere Regurgitation

Cardiac Transplant AssessmentCardiac Transplant AssessmentIndium-111 ImagingIndium-111 Imaging

Pulmonary Pulmonary HypertensionHypertension

Pulmonary EmbolismPulmonary Embolism V/Q V/Q ScanScan

Left to Right Shunt Left to Right Shunt First Pass First Pass StudyStudy

Normal First Pass StudyNormal First Pass Study

Left to Right Shunt

Qp/Qs= 2.6

A ratio of less than A ratio of less than 1.5 indicates a small 1.5 indicates a small left-to-right shunt. A left-to-right shunt. A ratio of 2.0 or more ratio of 2.0 or more indicates a large indicates a large left-to-right shuntleft-to-right shunt

Right to Left ShuntBody uptake of MAA > 6% of lung uptake

Secondary Secondary HypertensionHypertension

Renal Artery StenosisRenal Artery Stenosis Captopril Captopril Renogram StudyRenogram Study

PheochromocytomaPheochromocytoma I123 MIBG I123 MIBG ScanScan

PheochromocytomaPheochromocytomaII123123 MIBG Scan MIBG Scan

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