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Simplified approach to stress-first nuclear myocardial perfusion imaging: implementation of Choosing Wisely recommendations
  1. David Winchester,
  2. Randy Jeffrey,
  3. David Wymer,
  4. Vicente Taasan,
  5. Anita Wokhlu
  1. Malcom Randall VA Medical Center, Gainesville, Florida, USA
  1. Correspondence to Dr David Winchester; david.winchester{at}medicine.ufl.edu

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Introduction

Nuclear myocardial perfusion imaging (MPI) is a robust tool for detecting coronary artery disease (CAD) and for cardiovascular risk assessment. The radiation from MPI may marginally increase the patient’s risk of a malignancy in the future. Patient-centred risk mitigation strategies such as individualised radiotracer dosing and stress-first imaging are recommended by both clinical practice guidelines and the Choosing Wisely campaign.1–3 Implementation of stress-first imaging may be impaired by inadequate staffing, concerns about safety or perceived disruptions to workflow. We sought to address these perceived barriers and determine if a simplified, stress-first protocol would be feasible at our facility.

Methods

We adopted a stress-first imaging protocol for all patients undergoing MPI at our facility in which no pretest screening was performed and all patients were considered eligible for stress-first MPI. In preparation for adoption, we sought input from all members of the nuclear cardiology team. Nurses, technologists, housestaff and faculty all provided their opinions about possible barriers to success. One of the most prominent concerns was availability of a physician who could review stress-first studies throughout the day on short notice in order to make the decision about performing rest imaging. This duty was assigned to our advanced cardiovascular imaging fellow who was, in turn, responsible for securing adequate physician staffing if he was not going to be available.

The stress-first protocol was to inject 0.4 mg of regadenoson followed by 9–13 millicuries (mCi) of Tc-99m*-tetrofosmin. CT attenuation correction was used for all studies and prone imaging was acquired …

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