ASNC Preferred Practice StatementPatient-centered imaging
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)
- et al.
ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine
J Am Coll Cardiol
(2009) - et al.
ASNC information statement: Recommendations for reducing radiation exposure in myocardial perfusion imaging
J Nucl Cardiol
(2010) - et al.
ASNC imaging guidelines for nuclear cardiology procedures: Single photon-emission computed tomography
J Nucl Cardiol
(2010) - et al.
Normal stress-only versus standard stress/rest myocardial perfusion imaging: Similar patient mortality with reduced radiation exposure
J Am Coll Cardiol
(2010) - et al.
The prognosis of a normal stress-only Tc-99m myocardial perfusion imaging study
J Nucl Cardiol
(2010) - et al.
Low event rate for stress-only perfusion imaging in patients evaluated for chest pain
J Am Coll Cardiol
(2002) - et al.
Cost-saving approach to normal technetium-99m sestamibi myocardial perfusion scan
Am J Cardiol
(1996) - et al.
Multicenter investigation comparing a highly efficient half-time stress-only attenuation correction approach against standard rest-stress Tc-99m SPECT imaging
J Nucl Cardiol
(2009) - et al.
Stress-only or stress/rest myocardial perfusion imaging in patients undergoing evaluation for bariatric surgery
J Nucl Cardiol
(2011) Stress only myocardial perfusion imaging: Is it time for a change?
J Nucl Cardiol
(2010)
Stress-only myocardial perfusion imaging: A new paradigm
J Am Coll Cardiol
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
Imaging patients with chest pain in the Emergency Department
Clinical nuclear cardiology: State of the art and future directions
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
Technetium Tc 99m sestamibi myocardial perfusion imaging: Current role for evaluation of prognosis
Chest
Clinical value of attenuation correction in stress-only Tc-99m sestamibi SPECT imaging
J Nucl Cardiol
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
Recent technologic advances in nuclear cardiology
J Nucl Cardiol
High-speed myocardial perfusion imaging initial clinical comparison with conventional dual detector anger camera imaging
JACC Cardiovasc Imaging
Reduced isotope dose with rapid SPECT MPI imaging: Initial experience with a CZT SPECT camera
J Nucl Cardiol
Clinical results of a novel wide beam reconstruction method for shortening scan time of Tc-99m cardiac SPECT perfusion studies
J Nucl Cardiol
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
Wide beam reconstruction “quarter-time” gated myocardial perfusion SPECT functional imaging: A comparison to “full-time” ordered subset expectation maximum
J Nucl Cardiol
Prospective multicenter evaluation of rapid, gated SPECT myocardial perfusion upright imaging
J Nucl Cardiol
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
Reduced isotope dose and imaging time with a high-efficiency CZT SPECT camera
J Nucl Cardiol
New software methods to cope with reduced counting statistics: Shorter SPECT acquisitions and many more possibilities
J Nucl Cardiol
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
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
Incremental prognostic value of gated Rb-82 positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF
JACC Cardiovasc Imaging
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
Diagnostic accuracy of rest/stress ECG-gated Rb-82 myocardial perfusion PET: Comparison with ECG-gated Tc-99m sestamibi SPECT
J Nucl Cardiol
What is the prognostic value of myocardial perfusion imaging using rubidium-82 positron emission tomography?
J Am Coll Cardiol
Hibernating myocardium: Diagnosis and patient outcomes
Curr Probl Cardiol
A brief self-administered questionnaire to determine functional capacity (the Duke activity status index)
Am J Cardiol
Value of exercise treadmill testing in women
J Am Coll Cardiol
Detection of left anterior descending coronary artery stenosis in patients with left bundle branch block: Exercise, adenosine or dobutamine imaging?
J Am Coll Cardiol
Diagnosis of coronary artery disease by exercise thallium-201 tomography in patients with a right ventricular pacemaker
J Am Coll Cardiol
Detecting coronary artery disease in left bundle branch block
J Am Coll Cardiol
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
Safety of dipyridamole testing in 73,806 patients: The multicenter dipyridamole safety study
J Nucl Cardiol
Safety profile of adenosine stress perfusion imaging: Results from the Adenoscan multicenter trial registry
J Am Coll Cardiol
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
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
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
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
Effect of caffeine on ischemia detection by adenosine single-photon emission computed tomography perfusion imaging
J Am Coll Cardiol
Impact of acute propranolol administration on dobutamine-induced myocardial ischemia as evaluated by myocardial perfusion imaging and echocardiography
Am J Cardiol
ASNC information statement: The role of radionuclide myocardial perfusion imaging for asymptomatic individuals
J Nucl Cardiol
Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography
J Am Coll Cardiol
Cited by (0)
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.