ASNC IMAGING GUIDELINES ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers a b c Milena J. Henzlova, MD, W. Lane Duvall, MD, Andrew J. Einstein, MD, d e Mark I. Travin, MD, and Hein J. Verberne, MD a Mount Sinai Medical Center, New York, NY b Hartford Hospital, Hartford, CT c New York Presbyterian Hospital, Columbia University Medical Center, New York, NY d Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY e Academic Medical Center, Amsterdam, The Netherlands doi:10.1007/s12350-015-0387-x Abbreviations LEHR Low energy high resolution A2A Adenosine 2a LVEF Left ventricular ejection fraction AHA American Heart Association MBq Megabecquerels ALARA As low as reasonably achievable mCi Millicuries AV Atrioventricular MPI Myocardial perfusion imaging BP Blood pressure MRI Magnetic resonance imaging CBF Coronary blood flow mSv Millisievert CAD Coronary artery disease NE Norepinephrine CPET Cardiopulmonary exercise testing NET1 Norepinephrine transporter-1 DSP Deconvolution of septal penetration NPO Nil per os (nothing by mouth) ECG Electrocardiogram NYHA New York Heart Association EF Ejection fraction PET Positron emission tomography ESRD End-stage renal disease ROI Region of interest HF Heart failure SPECT Single-photon emission computed HFrEF Heart failure (with) reduced ejection tomography fraction TAVR Transcatheter aortic valve replacement HMR Heart-to-mediastinum ratio WR Washout rate ICD Implantable cardioversion defibrillator WPW Wolff-Parkinson White IV Intravenous LBBB Left bundle branch block EXERCISE STRESS TEST [including patients with acute chest pain without ischemia by electrocardiogram (ECG) and serum mark- Exercise testing has been used for more than 60 ers] and for prognosis and risk stratification in patients years for diagnostic purposes in symptomatic patients with known coronary artery disease (CAD), such as history of myocardial infarction or documented CAD by coronary angiography or computed tomography angiog- raphy and in those with high risk for the presence of Reprint requests: Milena J. Henzlova, MD, Mount Sinai Medical CAD, such as patients with diabetes mellitus, peripheral, Center, New York, NY; [email protected] or cerebral vascular disease. J Nucl Cardiol 1071-3581/$34.00 Copyright © 2016 American Society of Nuclear Cardiology. Henzlova et al Journal of Nuclear Cardiology® SPECT nuclear cardiology procedures Exerci se Modalities Undergoing Noncardiac Surgery: Executive Sum- (1) Exercise using a treadmill is done according to the mary: A Report of the American College of standardized protocols (most often the Bruce or Cardiology/American Heart Association Task Force 5 modified Bruce protocol) with incremental treadmill on Practice Guidelines; speed and incline (Tables 1, 2). (3) Clinician’s Guide to cardiopulmonary exercise test- 6 (2) Exercise using an upright or recumbent bicycle uses ing in adults: a scientific statement from the AHA. standard speed with incremental resistance. Exercise Testing Absolute Contraindications Detailed recommendations for exercise testing per- Absolute contraindications for exercise stress test- ing include the following: forman ce including (1) testing environment, (2) equipment [treadmill, bicycle, ECG monitoring, blood (1) High-risk unstable angina. However, patients with pressure (BP) monitoring], (3) emergency preparation chest pain syndromes at presentation who are and protocols, (4) patient preparation (including stable and without ECG evidence of ischemia and informed consent), (5) test performance, and (6) per- without serum biomarker evidence of myocardial sonnel qualifications are described in detail in the 2009 injury can undergo exercise stress testing. Recommendations for clinical exercise laboratories: a (2) Decompensated or inadequately controlled con- scientific statement from the American Heart Associa- gestive heart failure (HF). 1 tion (AHA). (3) Systolic BP at rest >200 mmHg or diastolic BP Performance of exercise testing describing normal at rest >110 mmHg. and abnormal response to exercise, evaluation of the test (4) Uncontrolled cardiac arrhythmias (causing symp- results are described in detail in 2013 Exercise Stan- toms or hemodynamic compromise). dards for Testing and Training: a scientific statement 7 2 (5) Severe symptomatic aortic stenosis. from the American Heart Association. (6) Acute pulmonary embolism. Recommendations for performance of exercise (7) Acute myocarditis or pericarditis. testing by nonphysicians (clinical exercise physiologists, (8) Acute aortic dissection. registered nurses, nurse practitioners, physician assis- (9) Severe pulmonary hypertension. tants, and physical therapists) as well as the role of 3 (10) Acute myocardial infarction (less than 2 to 4 days), supervising physician have been published recently. if clinically stable. Recommendations for testing specific populations (11) Acute symptomatic medical illness. [women, older adults, asymptomatic patients, prior to noncardiac surgery and exercise testing combined with cardiopulmonary exercise testing (CPET)] can be found Relative Contraindications in the following documents: Relative contraindications for exercise stress testing (1) Role of noninvasive testing in the clinical evaluation include the following: of women with suspected ischemic heart disease: a 4 consensus statement from the AHA; 1. Known significant left main coronary artery stenosis. 7 (2) 2014 ACC/AHA Guideline on Perioperative Car- 2. Asymptomatic severe aortic stenosis. diovascular Evaluation and Management of Patients Table 2. Modified Bruce Protocol Table 1. Bruce protocol Stage Mins. Speed, mph Grade, % Stage Mins. Speed, mph Grade, % 0 3 1.7 0 1/2 6 1.7 5 1 3 1.7 10 1 9 1.7 10 2 6 2.5 12 2 12 2.5 12 3 9 3.4 14 3 15 3.4 14 4 12 4.2 16 4 18 4.2 16 5 15 5.0 18 5 21 5.0 18 6 18 5.5 20 6 24 5.5 20 7 21 6.0 22 7 27 6.0 22 Journal of Nuclear Cardiology® Henzlova et al SPECT nuclear cardiology procedures stage of exercise, at peak exercise, and at the 3. Hypertrophic obstructive cardiomyopathy or other termination of recovery phase. In addition, in case forms of severe left ventricular outflow tract of abnormalities (e.g., arrhythmias, etc.) a 12-lead obstruction. Significant tachyarrhythmias or bradyarrhythmias. electrocardiogram should be obtained. 4. High-degree atrioventricular (AV) block. Electrolyte (5) The heart rate and BP should be recorded at least 5. abnormalities. every 3 minutes during exercise, at peak exercise, 6. Mental or physical impairment leading to inability to and for at least 4 minutes into the recovery phase. 7. exercise adequately. (6) The end point of all exercise tests should be If combined with imaging, patients with complete symptoms (moderate to severe chest pain, excessive 8. left bundle branch block (LBBB), permanent pace- shortness of breath, fatigue). Achievement of 85% makers, and ventricular pre-excitation [Wolff- of maximum, age-adjusted, predicted heart rate is Parkinson-White (WPW) syndrome] should prefer- not an indication for termination of the test. Note: In entially undergo pharmacologic vasodilator stress patients with known CAD (and particularly if tested test (not a dobutamine stress test). taking regular medication), the prognostic value of the test is preserved without reaching 85% of maximum predicted heart rate. (7) The radiopharmaceutical should be injected as Limitations close to peak exercise as possible. Patients should Exercise stress testing has a lower diagnostic value be encouraged to exercise for at least 1 minute in patients who cannot achieve an adequate heart rate after the radiotracer injection. If needed, treadmill and BP response due to a noncardiac physical limitation, speed and/or inclination can be decreased after such as pulmonary, peripheral vascular or musculoskele- tracer injection. tal abnormalities, or due to lack of motivation. These (8) Patients referred for a diagnostic stress test may be patients should be considered for pharmacologic stress converted to a pharmacologic stress test or a testing with myocardial perfusion imaging. Also, for a combination of both if they cannot exercise ade- meaningful test evaluation, exercise should last at least 4 quately for a meaningful period of time. to 6 minutes. Procedure (1) Patient preparation: nothing should be eaten at least Indications for Early Termination of 3 hours before the test. Patients scheduled for later Exercise in the morning or afternoon may have a light Indications for early termination of exercise include breakfast (e.g., cereal, fruit). Caffeine should be the following: avoided for at least 12 hours similar to vasodilatory stress testing because exercise stress tests, at times, (1) Moderate to severe angina pectoris. need to be converted to a pharmacologic stress test. (2) Marked dyspnea. If possible, insulin-dependent diabetics should be (3) Fatigue. scheduled for the morning hours. (4) Ataxia, dizziness, or near-syncope. (2) BP medication(s) with antianginal properties (β- (5) Signs of poor perfusion (cyanosis and pallor). blocker, calcium channel blocker, and nitrates) will (6) Patient’s request to terminate the test. lower a stress test’s diagnostic utility.8 Generally, (7) Excessive ST-segment depression (>2 mm discontinuation of these medicines is left to the from baseline). discretion of the referring physician. Regularly (8) ST elevation (>1 mm) in leads without taken medication should be recorded prior to testing. diagnostic (3) An intravenous (IV) cannula (larger size than