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Practical Guide for Interpreting and Reporting Cardiac PET

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Practical Guide for Interpreting and Reporting Cardiac PET Journal of Nuclear Medicine, published on March 31, 2021 as doi:10.2967/jnumed.121.261989 INFORMATION STATEMENT Practical guide for interpreting and reporting cardiac PET measurements of myocardial blood flow: an Information Statement from the American Society of Nuclear Cardiology, and the Society of Nuclear Medicine and Molecular Imaging Timothy M. Bateman, MD, MASNC,a Gary V. Heller, MD, PhD, MASNC,b Rob Beanlands, MD, MASNC,c Dennis A. Calnon, MD, MASNC,d James Case, PhD, MASNC,e Rob deKemp, PhD, FASNC,c E. Gordon DePuey, MD, MASNC,f Marcelo Di Carli, MD, MASNC,g,h Emel C. Guler, MD,c Venkatesh L. Murthy, MD, FASNC,i Jeffrey Rosenblatt, MD, FASNC,j Ronald Sher, MD,k Piotr Slomka, PhD, FASNC,l and Terrence D. Ruddy, MD, MASNCc a Saint-Luke’s Mid America Heart Institute and the University of Missouri – Kansas City, Kansas City, MO b Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ c University of Ottawa Heart Institute, Ottawa, Canada d OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, OH e Cardiovascular Imaging Technologies, Kansas City, MO f Icahn School of Medicine, Mount Sinai, Columbia University College of Physicians and Surgeons, New York, NY g Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA h Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA i Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI j Maine Medical Center, Portland, ME k Clinical Associates, Reisterstown, MD l Cedars Sinai Medical Center, Los Angeles, CA Received Jan 19, 2021; accepted Jan 19, 2021 doi:10.1007/s12350-021-02552-7 Key Words: Myocardial blood flow Æ MPI Æ PET < Modalities Æ 82 rubidium This article is being jointly published in The Journal of Nuclear J Nucl Cardiol Medicine (https://doi.org/10.2967/jnumed.121.261989) and the 1071-3581/$34.00 Journal of Nuclear Cardiology (https://doi.org/10.1007/s12350-021- Copyright Ó 2021 Society of Nuclear Medicine and Molecular 02552-7). Imaging, and American Society of Nuclear Cardiology. Reprint requests: Timothy M. Bateman, MD, MASNC, Saint-Luke’s Mid America Heart Institute and the University of Missouri – Kansas City, 4320 Wornall Road, Suite 2000, Kansas City, MO; [email protected] Bateman et al Journal of Nuclear CardiologyÒ Practical Guide for Interpreting and Reporting Cardiac PET Measurements of Myocardial Blood Flow Abbreviations PURPOSE OF THIS PRACTICAL GUIDE AC Attenuation correction One of the most exciting and useful advances in ASNC American Society of Nuclear nuclear cardiology is the opportunity to measure Cardiology myocardial blood flow (MBF) routinely as part of CAC Coronary artery calcium myocardial perfusion imaging (MPI) with positron CACS Coronary artery calcium score emission tomography (PET). Incorporating MBF into CAD Coronary artery disease the MPI evaluation improves diagnosis and assessment CT Computed tomography of extent and severity of epicardial coronary artery CTA Computed tomography angiography disease (CAD), reclassifies prognosis from assessment LAD Left anterior descending based solely on perfusion defects, confirms effectiveness LCx Left circumflex of pharmacologic stress, and can identify coronary LVEF Left ventricular ejection fraction microvascular disease with or without epicardial MBF Myocardial blood flow CAD.1–3 MBFR Myocardial blood flow reserve PET measurement of MBF assesses the entire MPI Myocardial perfusion imaging coronary circulation, including focal obstruction and PET Positron emission tomography diffuse disease of the epicardial coronary arteries, the RCA Right coronary artery functioning of the microvasculature, and the ability of RPP Rate pressure product the cell membrane to transport the radionuclide into the SNMMI Society of Nuclear Medicine and cell. MBF can be measured with the majority of Molecular Imaging dedicated PET or hybrid PET/CT scanners in use today. When using modern scanners, quantification of MBF Definitions Blood pool Measures the concentration of radio- adds no additional radiation or acquisition time. MBF input curve tracer activity in the blood as a function measurement is currently recognized by the Centers of of time. Typically measured in MBq/ Medicare and Medicaid Services as a Category 1 add-on (cm2s) or mCi/(cm2s) code for a PET MPI study. As such, quantification of MBF can and should be performed in appropriate Blood pool Software specific, small area, selected 3 region of for measuring the blood pool input patients as an adjunct to spatially relative MPI. At present, 82rubidium chloride (82Rb) and 13N- interest curve 13 ammonia ( NH3) are the most commonly used radio- Detector Occurs when the number of singles 15 saturation events being received at the scanner tracers for PET MPI and are both FDA-approved. O- exceeds the rate at which they can be water is more frequently used in Europe and is not FDA- approved. 18F-flurpiridaz is investigational and under accurately counted 13 15 Dynamic Consecutive series of short tomo- evaluation with a second phase III trial. NH3 and O- water require an on-site cyclotron due to their short half- scan graphic scans typically used to 82 measure radiotracer kinetics lives. Rb also has a short half-life and is generator produced. Measurement of MBF has been validated for Fused Overlay of the anatomical volume 82 13 15 2 Rb, NH3, and O-water. For this document, we display reconstruction (usually from a CT) 82 and the emission reconstruction have focused on PET quantification of MBF with Rb (PET). Used for quality control to due to its wider and increasing use, particularly in detect misregistration and anatomical centers where there may not be a sophisticated technical localization of tracer uptake infrastructure. There are two recommended references on PET Partial vol- Corrects the radiotracer uptake mea- 1 2 ume surement for the finite resolution of the MPI and principles of quantifying MBF. Interpreting correction PET scanner physicians are encouraged to read and understand these. Retention Used to determine the myocardial An important issue is the day-to-day implementation of methods blood flow from the integral of the MBF as a routine part of a PET MPI study. Busy clinical blood pool input curve and the final laboratories will need to develop technical infrastructure myocardial tracer uptake values to set design protocols, optimize quality control, train Single tis- Uses a dynamic model of the arterial technologists, educate interpreting physicians, and for- sue com- input function, myocardial uptake, and mulate clinical reports that incorporate clinically partment washout to calculate blood flow meaningful MBF measurements. The purpose of this model ‘‘primer’’ is to simplify and demystify MBF quantifi- cation, with the objective that practitioners develop Journal of Nuclear CardiologyÒ Bateman et al Practical Guide for Interpreting and Reporting Cardiac PET Measurements of Myocardial Blood Flow practical strategies for incorporating MBF measurement way to be certain that vasodilation and hence into daily clinical practice for care of their patients. augmentation of blood flow has occurred is by measuring MBF. IMPORTANT POINTS The ASNC and SNMMI have prepared and endorsed this document because these benefits can be • Measuring MBF with cardiac PET does not increase critically important to the comprehensive assessment of radiation or imaging time. patients being referred for pharmacologic MPI. • MBF can be measured with almost all PET scanners in use today, with proper attention to injected activity and acquisition protocols. IMPORTANT POINTS • MBF measurement improves diagnostic and prognos- • Traditional SPECT or PET MPI detects obstructive tic assessment, and thus may impact patient CAD but potentially under-assesses CAD extent and management. severity. • Measurement and reporting of MBF can be performed • MBF measurement improves assessment of epicardial with existing personnel. CAD. • PET MBF assesses the entirety of the coronary • MBF improves stratification of risk for major adverse delivery system including the epicardial coronaries cardiac events. and the microvasculature. • MBF measurement improves selection of patients for coronary interventions and/or medical therapy alone. • MBF measurement can identify coronary microvas- CLINICAL VALUE OF QUANTIFYING MBF cular disease. Traditional MPI relies on regional relative differ- • MBF measurement provides assurance that vasodila- ences in tracer uptake to diagnose flow-limiting CAD. tor stress has been effective. This has proved to be a valuable technique for popu- lation-based risk stratification and triaging patients for coronary angiography and interventions. However, tra- PRACTICAL TIPS FOR ENSURING CONSISTENT ditional MPI is intrinsically spatially relative and a MBF MEASUREMENTS myocardial region with apparently normal radiotracer MBF is dynamic, responding to changes in heart uptake may be supplied by a coronary artery with a rate and systolic blood pressure (double product), the flow-limiting lesion. As such, MPI tends to underesti- two main determinants of myocardial work. As such, mate the full extent of obstructive CAD4,5 and, in some there will be variability in a patient’s MBF from a cases, can appear normal despite prognostically impor- physiologic perspective. Another source of measurement tant disease.4 Quantification of MBF offers usefulness variability that can be controlled is adherence to patient
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