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Myocardial Perfusion Imaging (Revised Edition) Publications · Brochures Myocardial Perfusion Imaging (Revised Edition) A Technologist’s Guide Produced with the kind Support of Editors Ryder, Helen (Dublin) Testanera, Giorgio (Rozzano, Milan) Veloso Jerónimo, Vanessa (Almada) Vidovič, Borut (Munich) Contributors Abreu, Carla (London) Koziorowski, Jacek (Linköping) Acampa, Wanda (Naples) Lezaic, Luka (Ljubljana) Assante, Roberta (Naples) Mann, April (South Hadley) Ballinger, James (London) Medolago, Giuseppe (Bergamo) Fragoso Costa, Pedro (Oldenburg) Pereira, Edgar (Almada) Figueredo, Sergio (Lisbon) Santos, Andrea (Alverca do Ribatejo) Geão, Ana (Lisbon) Vara, Anil (Brighton) Ghilardi, Adriana (Bergamo) Zampella, Emilia (Naples) Holbrook, Scott (Gray) Contents Foreword 4 Introduction 5 Borut Vidovič Chapter 1 State of the Art in Myocardial Imaging 6 Wanda Acampa, Emilia Zampella and Roberta Assante Chapter 2 Clinical Indications 16 Luka Lezaic Chapter 3 Patient Preparation and Stress Protocols 23 Giuseppe Medolago and Adriana Ghilardi EANM Chapter 4 Multidisciplinary Approach and Advanced Practice 35 Anil Vara Chapter 5 Advances in Radiopharmaceuticals for Myocardial Perfusion Imaging 42 James R. Ballinger and Jacek Koziorowski Chapter 6 SPECT and SPECT/CT Protocols and New Imaging Equipment 54 Andrea Santos and Edgar Lemos Pereira Chapter 7 PET/CT Protocols and Imaging Equipment (*) 62 April Mann and Scott Holbrook Chapter 8 Image Processing and Software 77 Sérgio Figueiredo and Pedro Fragoso Costa Chapter 9 Artefacts and Pitfalls in Myocardial Imaging (SPECT, SPECT/CT and PET/CT) 109 Ana Geão and Carla Abreu Imprint 126 n accordance with the Austrian Eco-Label for printed matters. Eco-Label with the Austrian for n accordance (*) Articles were written with the kind support Printed i Printed of and in cooperation with: 3 Foreword The EANM Technologist Committee was dural workflow and need to cooperate with created more than 20 years ago. From the different professionals including nurses, phy- outset it worked not only to improve the pro- sicians, cardiologists and radiopharmacists. fessional expertise of nuclear medicine tech- nologists (NMTs) in Europe but also to assist The current book is specifically aimed at in raising the quality of Nuclear Medicine radiographers and technologists working clinical practice. Over the past two decades, or intending to work in a Nuclear Medicine it has developed continuously to become an department performing MPI; it will also have important group within the EANM. value for other healthcare professionals working or willing to work in this challenging With the above-mentioned goals of the environment. As you will see, some chapters Committee in mind, in early 2004 the idea from the previous edition of the guide have of providing a series of books on imaging for been revised and updated by the authors technologists was conceived. By September while new chapters and new contributors 2004, thanks to the hard work of the EANM have been added to extend and further im- Technologist Sub-committee on Education, prove the quality of the book. it was possible to publish the first Technolo- gist’s Guide, dedicated to myocardial perfu- I would like to thank all those who have sion scintigraphy. The success of this first contributed to the realisation of this project, guide led the Technologist Committee to whether as authors or reviewers, without propose a new book every year, starting a whom the book would not have been pos- series of guides that is still ongoing. sible. I also wish to thank SNMMITS (Society of Nuclear Medicine and Molecular Imaging The technological advancements in Nuclear Med- Technologist Section) and EANM Cardiovas- icine and Molecular Imaging of the past decade cular Committee for their help and high- have necessitated an upgrading of this pioneer- quality contributions. ing series, and the EANM Technologist Commit- tee accordingly decided to expand it to encom- Special thanks are due to Helen Ryder, Vanessa pass recent developments in scanner technology, Veloso Jerónimo and Borut Vidovič for their in- radiopharmaceuticals and stress tests. credible enthusiasm and competence in deal- ing with the editorial duties and organisation- Myocardial perfusion imaging (MPI) has a al work. Finally, I remain extremely grateful to leading role in cardiological diagnostic pro- the EANM Board, the EANM Executive Office, tocols due to its great efficiency in detecting the Technologist Committee and all the other ventricular perfusion defects with an almost EANM committees involved in the project. non-invasive procedure. MPI is, however, a challenging methodology for technologists, Giorgio Testanera who may cover various roles in the proce- Chair, EANM Technologist Committee 4 Introduction Borut Vidovič Cardiovascular diseases are the leading cause and the imaging equipment, with image of morbidity and mortality in the developed processing and software. The final chapter world, and their frequency is also increasing elucidates the causes and effects of potential in less developed countries [1]. Reliable and artefacts and pitfalls in myocardial perfusion rapid diagnosis is important to reduce the imaging. number of deaths and allow introduction of appropriate therapy at a very early stage of I would like to thank all the authors who have the disease. taken the time to write the chapters and all of my fellow editors who have helped to create Given that the last EANM Technologist’s this book. I hope all professionals who work Guide entitled Myocardial Perfusion Imaging in the area of Nuclear Medicine Cardiology or was released way back in 2004, it is certainly are interested in this topic will enjoy reading time for this new book. During the interven- and using the book. EANM ing period, Nuclear Medicine Cardiology has made great progress, with the development Reference of new radiopharmaceuticals for myocardial 1. http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/ perfusion imaging and the introduction of KS-30-08-357/EN/KS-30-08-357-EN.PDF, accessed July 2014 new imaging equipment with new post- processing programs. This book provides the reader with informa- tion on the current state of the art in myo- cardial imaging in Nuclear Medicine. It opens by introducing all the myocardial imaging methods, including those beyond Nuclear Medicine. The common clinical indications for myocardial perfusion scintigraphy are then discussed, followed by guidance on patient preparation and the different types of stress protocol and presentation of the main advantages and disadvantages of the multidisciplinary approach and advanced practice. Advances in radiopharmaceuticals for myocardial perfusion imaging are then introduced. The following three chapters are more technically oriented, enabling the reader to learn about the different SPECT, SPECT/CT, D-SPECT and PET/CT protocols 5 Chapter 1 State of the Art in Myocardial Imaging Wanda Acampa, Emilia Zampella and Roberta Assante Introduction Myocardial perfusion single-photon The prevalence of coronary artery disease emission computed tomography (CAD) is rising, and non-invasive myocardial Myocardial perfusion imaging is the stress imaging is increasingly being used to: imaging procedure that is most widely used in the management of patients with coro- • Detect obstructive CAD and define the nary artery disease (CAD) [1]. Gated MPS pro- number, location and significance of coro- vides important information on the extent nary stenoses and severity of myocardial perfusion abnor- malities, including myocardial ischaemia, • Guide medical therapy and monitor the left ventricular (LV) cavity size and function, treatment effect after revascularisation and mechanical dyssynchrony. Moreover, it procedures can deliver miscellaneous prognostic imag- • Risk stratify patients and provide prognos- ing data regarding, for example, transient tic information ischaemic dilation (TID), lung uptake, right ventricular uptake, post-stress left ventricu- • Assess myocardial viability lar ejection fraction (LVEF) and sphericity in- Nuclear myocardial perfusion imaging pro- dex. One of the reasons for use of MPS in the cedures, such as myocardial perfusion single- management of patients with suspected or photon emission computed tomography known CAD is that it can be performed in any (MPS) and positron emission tomography patient, even in those with a poor “acoustic (PET), have emerged not only as diagnostic window”, implanted metal objects, cardiac techniques but also as robust prognostic dysrhythmias or renal dysfunction. With the tools able to provide data about myocardial introduction of pharmacological stressor perfusion, ventricular function and viability agents, MPS can now be safely performed in by means of a single test. most patients who would not be candidates for exercise stress, thereby adding flexibil- Several other imaging modalities are avail- ity in testing strategy and affording greater able for evaluation of the presence and se- availability of the test to virtually all patients. verity of CAD, including echocardiography, The concern of radiation exposure, although cardiac computed tomography and cardiac a real one, has been proactively addressed magnetic resonance imaging (CMR). The through scientific innovation and appropri- most appropriate imaging modality should ate changes in MPS guidelines. The introduc- be chosen according to the clinical question, tion of new-generation gamma cameras, patient characteristics, strengths, limitations, which allow acquisition of high-quality im- risks, costs and availability.
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