© 2003 by the American College of Cardiology Foundation and the American Heart Association, Inc. ACC/AHA PRACTICE GUIDELINES—FULL TEXT ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging 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 Cardiac Radionuclide Imaging) COMMITTEE MEMBERS Francis J. Klocke, MD, MACC, FAHA, Chair Michael G. Baird, MD, FACC, FAHA Beverly H. Lorell, MD, FACC, FAHA Timothy M. Bateman, MD, FACC, FAHA Joseph V. Messer, MD, MACC, FAHA Daniel S. Berman, MD, FACC, FAHA Patrick T. O’Gara, MD, FACC, FAHA Blase A. Carabello, MD, FACC, FAHA Richard O. Russell, Jr., MD, FACC Manuel D. Cerqueira, MD, FACC, FAHA Martin G. St. John Sutton, MBBS, FACC Anthony N. DeMaria, MD, MACC, FAHA James E. Udelson, MD, FACC J. Ward Kennedy, MD, MACC, FAHA Mario S. Verani, MD, FACC* Kim Allan Williams, MD, FACC, FAHA TASK FORCE MEMBERS Elliott M. Antman, MD, FACC, FAHA, Chair Sidney C. Smith, Jr., MD, FACC, FAHA, Vice Chair Joseph S. Alpert, MD, FACC, FAHA Raymond J. Gibbons, MD, FACC, FAHA†** Gabriel Gregoratos, MD, FACC, FAHA Loren F. Hiratzka, MD, FACC, FAHA Jeffrey L. Anderson, MD, FACC Sharon Ann Hunt, MD, FACC, FAHA David P. Faxon, MD, FACC, FAHA Alice K. Jacobs, MD, FACC, FAHA Valentin Fuster, MD, PhD, FACC, FAHA Richard O. Russell, MD, FACC, FAHA** *Deceased ber): Up to 999 copies, call 1-800-611-6083 (US only) or fax 413-665-2671; **Former Task Force Member 1000 or more copies, call 214-706-1466, fax 214-691-6342, or e-mail pub- †Former Task Force Chair [email protected]. This document was approved by the American College of Cardiology Foundation Board of Trustees in July 2003, the American Heart Association Science Advisory and Coordinating Committee in July 2003, and the American TABLE OF CONTENTS Society of Nuclear Cardiology Board of Directors in July 2003. When citing this document, the American College of Cardiology Foundation, Preamble ...................................................................................2 the American Heart Association, and the American Society of Nuclear Cardiology request that the following citation format be used: Klocke FJ, Baird I. Introduction....................................................................... 3 MG, Bateman TM, Berman DS, Carabello BA, Cerqueira MD, DeMaria AN, II. Acute Syndromes...............................................................4 Kennedy JW, Lorell BH, Messer JV, O’Gara PT, Russell RO Jr., St. John Sutton MG, Udelson JE, Verani MS, Williams KA. ACC/AHA/ASNC guidelines for A. Myocardial Perfusion Imaging in the Assessment of the clinical use of cardiac radionuclide imaging: a report of the American Patients Presenting With Chest Pain to the College of Cardiology/American Heart Association Task Force on Practice Emergency Department.................................................4 Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for B. Detection of AMI When Conventional Measures Are the Clinical Use of Radionuclide Imaging). (2003). American College of Nondiagnostic...............................................................6 Cardiology Web Site. Available at: http://www.acc.org/clinical/ 1. “Hot Spot” Infarct Imaging.......................................6 guidelines/radio/rni_fulltext.pdf. 2. Acute Rest Myocardial Perfusion Imaging...............7 This document is available on the World Wide Web sites of the American C. Radionuclide Testing in Risk Assessment: College of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), and the American Society of Nuclear Cardiology Prognosis and Assessment of Therapy After STEMI...7 (www.asnc.org). Single copies of this document are available by calling 1-800- D. Radionuclide Testing in Risk Assessment: 253-4636 or writing the American College of Cardiology Foundation, Resource Prognosis and Assessment of Therapy After NSTEMI Center, at 9111 Old Georgetown Road, Bethesda, MD 20814-1699. Ask for or UA.............................................................................8 reprint number 71-0266. To obtain a reprint of the Executive Summary pub- lished in the October 1, 2003 issue of the Journal of the American College of III. Chronic Syndromes..........................................................9 Cardiology and the September 16, 2003 issue of Circulation, ask for reprint A. Detection (Diagnosis) of CAD.....................................9 number 71-0265. To purchase bulk reprints (specify version and reprint num- 1. Sensitivity and Specificity.........................................9 ACC - www.acc.org Klocke et al. 2003 AHA - www.americanheart.org 2 ACC/AHA/ASNC Practice Guidelines ASNC - www.asnc.org 2. Effect of Referral Bias............................................11 Vasculopathy............................................................35 3. Quantitative Analysis..............................................12 5. Chagas Myocarditis and/or Cardiomyopathy..........36 4. ECG-Gated SPECT.................................................12 6. Sarcoid Heart Disease.............................................36 5. Attenuation Correction............................................13 7. Cardiac Amyloidosis.............................................. 36 6. Positron Emission Tomography..............................14 8. RV Dysplasia...........................................................36 B. Management of Patients With Known or Suspected 9. Hypertrophic Cardiomyopathy................................37 Chronic CAD: Assessment of Disease Severity, Risk 10. Hypertensive Heart Disease....................................37 Stratification, and Prognosis.......................................14 11. Valvular Heart Disease............................................38 1. Nongated MPI.........................................................15 12. Adults With Congenital Heart Disease...................40 2. Gated SPECT..........................................................18 Appendix 1: Procedures and Principles..................................40 3. Radionuclide Angiography......................................18 A. Introduction to Nuclear Cardiology............................40 4. Cost Effectiveness...................................................18 B. Nuclear Cardiology Instrumentation...........................40 5. Frequency of Testing...............................................19 C. Radiopharmaceuticals.................................................41 6. Evaluation of the Effects of Medical Therapy........19 1. Single-Photon MPI..................................................41 C. Specific Patient Populations........................................19 2. Positron Emission Tomography..............................41 1. African Americans.................................................. 19 3. First-Pass RNA........................................................42 2. Women.....................................................................19 4. Gated-Equilibrium RNA.........................................42 3. Normal Resting ECG, Able to Exercise................. 19 D. Image Acquisition, Analysis, and Display..................42 4. Intermediate-Risk Duke Treadmill Score...............20 1. SPECT MPI.............................................................42 5. Normal Resting ECG, Unable to Exercise............. 20 2. Planar MPI..............................................................42 6. LBBB/Pacemakers..................................................20 3. PET Perfusion Imaging...........................................43 7. Left Ventricular Hypertrophy..................................21 4. First-Pass RNA........................................................43 8. Patients With Nonspecific ST-T Wave Changes.....21 5. ECG-Gated Planar Equilibrium Blood Pool 9. Elderly.....................................................................21 RNA.........................................................................43 10. Asymptomatic Patients........................................... 21 6. ECG-Gated Tomographic Equilibrium Blood Pool 11. Obese Patients.........................................................22 Imaging....................................................................43 12. Diabetes...................................................................22 E. Quality Assurance, Artifact Detection, and 13. After Coronary Calcium Screening........................22 Correction....................................................................44 14. Before and After Revascularization........................22 1. Quality Control....................................................... 44 15. Radionuclide Imaging Before Noncardiac 2. Attenuation Correction............................................45 Surgery.....................................................................23 3. Motion Correction and Depth-Dependent D. Recommendations: Cardiac Stress Myocardial Blurring...................................................................45 Perfusion SPECT in Patients Able to Exercise...........24 F. Clinical Procedures......................................................45 E. Recommendations: Cardiac Stress Myocardial 1. Myocardial Perfusion Imaging................................45 Perfusion SPECT in Patients Unable to Exercise.......26 2. Analysis of Ventricular Function.............................50 F. Recommendations: Cardiac Stress Myocardial 3. Myocardial