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Nuclear Cardiology

Dyna Evalina Syahlul,


BMedSci, SpJP
RSPAD Gatot Soebroto DITKESAD

SPECT
Single Photon Emission Computed Tomography

A nuclear medicine
tomography imaging
technique using gamma rays
and gamma camera to
acquire multiple 2-D images
from multiple angles

SPECT Principles

SPECT Display

Thallium Protocols
Procedures Tracer is administered during stress or at rest
Result :

Reversibly
Thallium injected during stress
ischemic, Viable Thallium defect redistribution delayed 3 to 4 hrs
or 24 hrs
myocardium
Viable
Thallium injected at rest
myocardium,
Delayed redistribution images
resting
hypoperfusion
Scarred
Thallium defect persist overtime
myocardium
Patient with severe CAD but viable myocardium no
redistribution phase because of decline of blood thallium
level
Test for viable myocardium re-injecting small dose of
Thallium at rest

Thallium Protocols

TC-99m Protocols
Require two separates injection (at
peak stress and at rest)
Basic protocols :
1)Single day study
2) 2-day study
3)Dual isotope technique

Single Day Study

2-Day Study

- Patient with large body


habitus
- High doses of tracers at
both at stress and at peak

Dual Isotop Technique

Combined Tracers
At rest : Thallium
At stress : Tc-99m
Advantages
High quality of imaging (Tc-99m)
Potential of acquiring redistribution

SPECT IMAGE OF INTERPRETATION


AND REPORTING

Visual

Subjective interpretation
Describing perfusion pattern
on stress dan whether the
defect is reversible or
irreversibel

Semi Quantitative
Divided myocardium

17
segments
into

Grade of perfusion
from

0-4

SSS (Summed Stress Score)

The extent and severity of stress


perfusion abnormality
Predictor of natural history
outcomes

SRS (Summed Rest Score)


The extent of infarct

SDS (Summed Difference


Score)

SSS-SRS
The extent and
severity of stressinduced ischemia

Quantitative

Creation of a
circumferential profile
of relative tracers
activity around
tomogram

Highly
reproducible
Disadvatages
Account potential
artifact

Principles
Scintigraphic acquisition
data conjunction with ECG
Detecting R wave
Images :
end diastole
end systole wall
thickening and
brightening

Visual
analysis :
Normal : brighten normally
Hypokinetic : diminished but
apparent brightening
Severe hypokinetic : slight
brightening
Akinetic : no apparent
brightening

Quantitative
analysis :
Apparent epicardial and
endocardial borders in all three
orthogonal planes
creating a 3D surface-rendered
image of LV
Accompanied by automated
calculation of EF and LV
volumes

Risk Stratification
Based on extent of ischemia region :
<4 : low risk
4-8 : moderate
8-13 : high risk
> 13 : very high risk
LVEF < 30% : high risk
high ESV : high risk

Take a
Deep
Breath....

Pharmacological stress
For the patients who are unable to
exercise or unable to achieve
maximal exercise
Classified into 2 categories :
vasodilator (adenosine and dipyridamol)
adrenergic stimulant (dobutamine)

Vasodilator
Mechanism :

Systemic
effect

8 to 10 mm
Hg in systolic
and diastolic BP

heart rate

Vasodilator
agents
(dipyridamole
& adenosine)

Side effect
(effect os
adenosine
stimulation)

AV block
10 % : 1st degree
5 % : 2nd&3rd
degree

Ischemic ST
depression
Flushing, chest
pain, shortness
of breathiness

Antagonize

Metilxanthine
compounds
(Teophylline,
aminophylline)

Adrenergic stimulants
For patient who contraindicated with vasodilator
agent because of reactive bronchospasm or
taking metilxanthine
Dobutamine is given starting at a dose of 5
mcg/kg/min and increased in a stepwise fashion
by 5 mcg/kg/min every 3 minutes, to a
maximum dose of 40 mcg/kg/min
Side effect : palpitations and chest pain, and
arrhythmias (inc. PVC, VT), hypotension

Disease Detection, Risk Stratification,


and Clinical Decision Making

1. Stable Chest Pain


2. Acute Coronary Syndrome
3. Heart Failure
4. Assess Cardiac Risk Prior to Non
Cardiac Surgery

SPECT imaging :
Sensitivity to detect CAD was 87% (71-97%)
Specificity to rule out CAD was 73% (36-100%)

Physiological influences on sensitivity


and specificity:
LBB, hypertrophic/dilated
cardiomyopathy, LVH, Endothelial
dysfunction

Acute Coronary Syndrome


SPECT sestamibi :
Sensitivity : 92 % in detecting Acute MI
(Trop I in 1st hour only 39 %)

ACC/AHA/ASNC Radionuclide Imaging


Guidelines :
Indication : SPECT MPI in ED patients
with suspected ACS but no definitive
ECG changes (class I, level A)

NSTEMI :
Patient with positive biomarkers, intermediate or
low TIMI risk stress MPI for risk stratification
ACC/AHA/ASNC Radionuclide Imaging Guidelines :
Indication : detecting residual ischemia (class I)

STEMI :
Patients surviving the initial acute period may
have a relatively stable course MPI for risk
stratification

Heart Failure
To determine etiology of heart failure
CAD or non ischemic disease
Non-ischemic cardiomyopathy may
have patchy and large confluent
territories of fibrosis or scaring with
MRI, and manifest as fixed defect on
SPECT MPI

Assess Cardiac Risk Prior to Non-cardiac


Surgery
Important : preventive and prognostic indicator
Initial cardiac assessment :

The prevalence of CAD in a given surgical population


The type of surgical procedure
Cardiac history and risk factor
Functional capacity

Clinical parameter of increased risk :

Advance age (>70 yrs old)


Diabetic
History of angina or recent ACS
Heart failure
Ventricular arrhythmias

SUMMARY
INDICATIONS CARDIAC NUCLEAR
IMAGING

SUMMARY
CONTRAINDICATIONS OF CARDIAC NUCLEAR
IMAGING

APPROPRIATE USE CRITERIA


NUCLEAR

Thank
You....