ASNC Preferred Practice Statement
Patient-centered imaging

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Introduction

The continued success of nuclear cardiology demands ongoing re-evaluation of imaging practices to optimize patient care. The first element of this process is to accurately define candidates for imaging. Appropriate use criteria documents provide such guidelines.1 A second equally important element is choosing the proper imaging procedure for the individual patient. Tailoring imaging to the patient is critical for providing accurate and clinically meaningful information to the physician. There are several integral components to a successful patient-centered imaging approach.

Patient safety is of paramount importance when contemplating any diagnostic and/or therapeutic medical option. For myocardial perfusion imaging (MPI) this approach includes not only the risk of the stress protocol but also the “risk” of performing unnecessary additional procedures or administering inappropriate therapy because of a sub-optimally performed test. High-quality imaging limits the latter through improved diagnostic sensitivity and specificity, enhanced risk stratification, and less intra- and inter-observer variability when interpreting clinically significant changes in serial images.

Another safety consideration is the risk from radiation exposure which should be weighed in each individual patient prior to initiating a study. There has been a recent dramatic increase in public awareness and media focus on radiation exposure. Consequently, a major factor influencing the choice of MPI protocol is radiopharmaceutical dose. This issue is particularly relevant to younger patients and in women of childbearing potential. However, even in older individuals and in those in whom the risk/benefit ratio is low, radiation exposure should be limited to that dose required to obtain a diagnostic study. Protocols that minimize radiation exposure have been proposed recently by a different ASNC writing group and should be considered when evaluating a patient.2 The patient radiopharmaceutical doses cited in this article are based upon effective radiation exposure from tissue dose coefficients, using International Commission on Radiological Protection (ICRP) Publication 103 weighting factors.2,3

Once safety concerns are addressed, it is critical to ensure that the proper imaging protocol is used to best answer the clinical question at hand. Meeting this priority requires close communication between the referring physician and those performing the test.

Finally, it is important to consider cost as well as overall patient convenience and satisfaction. Protocols requiring prolonged or return visits are regarded unfavorably by both patients and their referring physicians and significantly decrease laboratory efficiency. Every effort should be made to streamline procedures.

This document will address the advantages and disadvantages of currently available stressor and imaging options as well as provide a framework for imaging specific patients through case-based scenarios.

Section snippets

Part 1: Single Photon Emission Computed Tomography (SPECT) MPI Protocols

There are several general themes regarding the choice of a SPECT MPI protocol. First, exercise stress is preferred over pharmacologic stress testing in patients who can exercise to a maximal workload. However, in patients unable to exercise, pharmacologic stressors have greatly enhanced nuclear cardiology by providing flexibility and broadening patient accessibility to SPECT procedures. Second, radiopharmaceuticals that limit radiation exposure and improve overall image quality, such as the

Acknowledgments

Disclaimer

This Information Statement has been prepared from publicly available information and is intended for the personal use of ASNC members. Its purpose is to provide objective information and analysis on a timely basis; it is not intended to be prescriptive or definitive as to appropriate medical practice or minimal standards of care for patients. In addition, the standards discussed may not be appropriate for all practice settings or for all patients. ASNC expressly disclaims any liability for

References (168)

  • IskandrianAE

    Stress-only myocardial perfusion imaging: A new paradigm

    J Am Coll Cardiol

    (2010)
  • SciagràR et al.

    Comparison of baseline-nitrate technetium-99m sestamibi with rest-redistribution thallium-201 tomography in detecting viable hibernating myocardium and predicting postrevascularization recovery

    J Am Coll Cardiol

    (1997)
  • KontosMC et al.

    Imaging patients with chest pain in the Emergency Department

    Clinical nuclear cardiology: State of the art and future directions

    (2010)
  • HellerGV et al.

    Clinical value of acute rest technetium-99m tetrofosmin tomographic myocardial perfusion imaging in patients with acute chest pain and nondiagnostic electrocardiograms

    J Am Coll Cardiol

    (1998)
  • MandalapuBP et al.

    Technetium Tc 99m sestamibi myocardial perfusion imaging: Current role for evaluation of prognosis

    Chest

    (1999)
  • HellerGV et al.

    Clinical value of attenuation correction in stress-only Tc-99m sestamibi SPECT imaging

    J Nucl Cardiol

    (2004)
  • EinsteinAJ et al.

    Agreement of visual estimation of coronary artery calcium from low-dose CT attenuation correction scans in hybrid PET/CT and SPECT/CT with standard Agatston score

    J Am Coll Cardiol

    (2010)
  • PattonJA et al.

    Recent technologic advances in nuclear cardiology

    J Nucl Cardiol

    (2007)
  • SharirT et al.

    High-speed myocardial perfusion imaging initial clinical comparison with conventional dual detector anger camera imaging

    JACC Cardiovasc Imaging

    (2008)
  • DuvallWL et al.

    Reduced isotope dose with rapid SPECT MPI imaging: Initial experience with a CZT SPECT camera

    J Nucl Cardiol

    (2010)
  • Borges-NetoS et al.

    Clinical results of a novel wide beam reconstruction method for shortening scan time of Tc-99m cardiac SPECT perfusion studies

    J Nucl Cardiol

    (2007)
  • DePueyEG et al.

    Ordered subset expectation maximization and wide beam reconstruction “half-time” gated myocardial perfusion SPECT functional imaging: A comparison to “full-time” filtered backprojection

    J Nucl Cardiol

    (2008)
  • DePueyEG et al.

    Wide beam reconstruction “quarter-time” gated myocardial perfusion SPECT functional imaging: A comparison to “full-time” ordered subset expectation maximum

    J Nucl Cardiol

    (2009)
  • MaddahiJ et al.

    Prospective multicenter evaluation of rapid, gated SPECT myocardial perfusion upright imaging

    J Nucl Cardiol

    (2009)
  • DePueyEG et al.

    A comparison of the image quality of full-time myocardial perfusion SPECT vs. wide beam reconstruction half-time and half-dose SPECT

    J Nucl Cardiol

    (2011)
  • DuvallWL et al.

    Reduced isotope dose and imaging time with a high-efficiency CZT SPECT camera

    J Nucl Cardiol

    (2011)
  • DePueyEG

    New software methods to cope with reduced counting statistics: Shorter SPECT acquisitions and many more possibilities

    J Nucl Cardiol

    (2009)
  • KlockeFJ et al.

    ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging—executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Radionuclide Imaging)

    J Am Coll Cardiol

    (2003)
  • MahmarianJJ et al.

    An initial strategy of intensive medical therapy is comparable to that of coronary revascularization for suppression of scintigraphic ischemia in high-risk but stable survivors of acute myocardial infarction

    J Am Coll Cardiol

    (2006)
  • DorbalaS et al.

    Incremental prognostic value of gated Rb-82 positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF

    JACC Cardiovasc Imaging

    (2009)
  • KleinR et al.

    Intra- and inter-operator repeatability of myocardial blood flow and myocardial flow reserve measurements using rubidium-82 pet and a highly automated analysis program

    J Nucl Cardiol

    (2010)
  • BatemanTM et al.

    Diagnostic accuracy of rest/stress ECG-gated Rb-82 myocardial perfusion PET: Comparison with ECG-gated Tc-99m sestamibi SPECT

    J Nucl Cardiol

    (2006)
  • YoshinagaK et al.

    What is the prognostic value of myocardial perfusion imaging using rubidium-82 positron emission tomography?

    J Am Coll Cardiol

    (2006)
  • SchinkelAFL et al.

    Hibernating myocardium: Diagnosis and patient outcomes

    Curr Probl Cardiol

    (2007)
  • HlatkyMA et al.

    A brief self-administered questionnaire to determine functional capacity (the Duke activity status index)

    Am J Cardiol

    (1989)
  • AlexanderKP et al.

    Value of exercise treadmill testing in women

    J Am Coll Cardiol

    (1998)
  • VaduganathanP et al.

    Detection of left anterior descending coronary artery stenosis in patients with left bundle branch block: Exercise, adenosine or dobutamine imaging?

    J Am Coll Cardiol

    (1996)
  • LakkisNM et al.

    Diagnosis of coronary artery disease by exercise thallium-201 tomography in patients with a right ventricular pacemaker

    J Am Coll Cardiol

    (1997)
  • IskandrianAE

    Detecting coronary artery disease in left bundle branch block

    J Am Coll Cardiol

    (2006)
  • MahmarianJJ et al.

    A multinational study to establish the value of early adenosine technetium-99m sestamibi myocardial perfusion imaging in identifying a low-risk group for early hospital discharge after acute myocardial infarction

    J Am Coll Cardiol

    (2006)
  • LetteJ et al.

    Safety of dipyridamole testing in 73,806 patients: The multicenter dipyridamole safety study

    J Nucl Cardiol

    (1995)
  • CerqueiraMD et al.

    Safety profile of adenosine stress perfusion imaging: Results from the Adenoscan multicenter trial registry

    J Am Coll Cardiol

    (1994)
  • HaysJT et al.

    Dobutamine thallium-201 tomography for evaluating patients with suspected coronary artery disease unable to undergo exercise or vasodilator pharmacologic stress testing

    J Am Coll Cardiol

    (1993)
  • CerqueiraMD et al.

    Effects of age, gender, obesity, and diabetes on the efficacy and safety of the selective A2A agonist regadenoson versus adenosine in myocardial perfusion imaging integrated ADVANCE-MPI trial results

    JACC Cardiovasc Imaging

    (2008)
  • LeakerBR et al.

    Safety of regadenoson, an adenosine A2A receptor agonist for myocardial perfusion imaging in mild asthma and moderate asthma patients: A randomized, double-blind placebo-controlled trial

    J Nucl Cardiol

    (2008)
  • ThomasGS et al.

    Safety of regadenoson, a selective adenosine A2A agonist, in patients with chronic obstructive pulmonary disease: A randomized, double-blind, placebo-controlled trial (RegCOPD trial)

    J Nucl Cardiol

    (2008)
  • ZoghbiGJ et al.

    Effect of caffeine on ischemia detection by adenosine single-photon emission computed tomography perfusion imaging

    J Am Coll Cardiol

    (2006)
  • ShehataAR et al.

    Impact of acute propranolol administration on dobutamine-induced myocardial ischemia as evaluated by myocardial perfusion imaging and echocardiography

    Am J Cardiol

    (1997)
  • HendelRC et al.

    ASNC information statement: The role of radionuclide myocardial perfusion imaging for asymptomatic individuals

    J Nucl Cardiol

    (2011)
  • BermanDS et al.

    Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography

    J Am Coll Cardiol

    (2004)
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    Unless reaffirmed, retired, or amended by express action of the Board of Directors of the American Society of Nuclear Cardiology, this Information Statement shall expire as of March 1, 2017,

    An erratum to this article can be found at doi:10.1007/s12350-012-9540-y.

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