Eur J Nucl Med Mol Imaging DOI 10.1007/s00259-007-0694-9 GUIDELINES EANM/ESC guidelines for radionuclide imaging of cardiac function B. Hesse & T. B. Lindhardt & W. Acampa & C. Anagnostopoulos & J. Ballinger & J. J. Bax & L. Edenbrandt & A. Flotats & G. Germano & T. Gmeiner Stopar & P. Franken & A. Kelion & A. Kjaer & D. Le Guludec & M. Ljungberg & A. F. Maenhout & C. Marcassa & J. Marving & F. McKiddie & W. M. Schaefer & L. Stegger & R. Underwood # EANM 2008 Abstract Radionuclide imaging of cardiac function repre- gated PET, and studies with non-imaging devices for the sents a number of well-validated techniques for accurate evaluation of cardiac function. The items covered are determination of right (RV) and left ventricular (LV) presented in 11 sections: clinical indications, radiopharma- ejection fraction (EF) and LV volumes. These first ceuticals and dosimetry, study acquisition, RV EF, LV EF, European guidelines give recommendations for how and LV volumes, LV regional function, LV diastolic function, when to use first-pass and equilibrium radionuclide ven- reports and image display and reference values from the triculography, gated myocardial perfusion scintigraphy, literature of RVEF, LVEF and LV volumes. If specific B. Hesse (*) : A. Kjaer : J. Marving L. Edenbrandt Department of Clinical Physiology and Nuclear Medicine, Department of Clinical Sciences, Malmö, Lund University University Hospital of Copenhagen, Research Program in Medical Informatics, Rigshospitalet, Malmö University Hospital, Copenhagen, Denmark Malmö, Sweden e-mail: [email protected] A. Flotats T. B. Lindhardt Nuclear Medicine Department, Department of Cardiology, Hilleroed Hospital, Autonomous University of Barcelona, Hilleroed, Denmark Hospital de la Santa Creu i Sant Pau, Barcelona, Spain W. Acampa Department of Biomorphological and Functional Sciences, G. Germano Institute of Biostructure and Bioimages of the National Artificial Intelligence Program at Cedars-Sinai Medical Center Council of Research, University of Naples Federico II, and Department of Medicine of the University of California at Naples, Italy Los Angeles, Los Angeles, USA C. Anagnostopoulos : A. F. Maenhout Department of Nuclear Medicine, Royal Brompton Hospital, T. G. Stopar London, UK Department of Nuclear Medicine, University Medical Centre Ljubljana, J. Ballinger Radiopharmacy and Clinical Biochemistry, Department of Nuclear Medicine, Ljubljana, Guy’s Hospital–Guy’s and St. Thomas’ Foundation Trust, Zaloska 7, Slovenia St. Thomas Street, London, UK P. Franken Nuclear Medicine, AZ VUB, J. J. Bax Brussels, Belgium Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands Eur J Nucl Med Mol Imaging recommendations given cannot be based on evidence from LVEF left ventricular ejection fraction original, scientific studies, referral is given to “prevailing or MI myocardial infarction general consensus”. The guidelines are designed to assist in MPS myocardial perfusion scintigraphy the practice of referral to, performance, interpretation and NSTEMI non-ST elevation acute myocardial infarction reporting of nuclear cardiology studies for the evaluation of PFR peak filling rate cardiac performance. PFRSV PFR normalised to stroke volume QGS quantitative gated SPECT Keywords Nuclear imaging . EANM/ESC guidelines . RAO right anterior oblique Cardiac function RBC red blood cells RNV radionuclide ventriculography Abbreviations ROI region-of-interest ACD acid citrate dextrose RV right ventricle CAD coronary artery disease STEMI ST elevation acute myocardial infarction cMRI cardiac magnetic resonance imaging TAC time–activity curve ECG electrocardiogram TID transient ischaemic dilatation ECT Emory Cardiac Toolbox TPFR time to peak filling rate ED end-diastolic WM wall motion EDV end-diastolic volume WTh wall thickening ES end-systolic EF ejection fraction ERNV equilibrium radionuclide ventriculography ESV end-systolic volume Preamble FP first pass FPRNV first-pass radionuclide ventriculography The European guidelines for radionuclide imaging of HSA human serum albumin cardiac function have been developed under the auspices i.v. intravenous of the European Council on Nuclear Cardiology (the joint LAO left anterior oblique group of the Cardiovascular Committee of the European LBBB left bundle branche block Association of Nuclear Medicine and of the Working Group LEGP low energy general purpose on Nuclear Cardiology of the European Society of LEHR low energy high resolution Cardiology). The aim of the authors has been to present LEHS low energy high sensitivity the state-of-the-art applications and protocols approved by LPO left posterior oblique experts in the field and to disseminate this information to LV left ventricle the European nuclear cardiology community. The guide- LVV left ventricular volume lines are designed to assist physicians and other healthcare A. Kelion W. Schaefer Nuclear Medicine Department, Harefield Hospital, Nuclear Medicine Department, University Hospital, Harefield, Middlesex, UK Aachen University of Technology, Aachen, Germany D. Le Guludec Service de medecine nucleaire, hôpital Bichat, APHP, L. Stegger Université Denis-Diderot, UMR577B, and Inserm U773, Department of Nuclear Medicine, University Hospital Münster, Paris, France Münster, Germany M. Ljungberg R. Underwood Medical Radiation Physics, Clinical Sciences, Department of Nuclear Medicine, Royal Brompton Hospital, Lund, Lund University, London, UK Lund, Sweden C. Marcassa Department of Cardiology, Fondazione Maugeri, IRCCS, Veruno, Italy F. McKiddie Nuclear Medicine Department, Aberdeen Royal Infirmary, Foresterhill Aberdeen, Scotland, UK Eur J Nucl Med Mol Imaging professionals in referring to, performing, interpreting and The use of radionuclide imaging was addressed in the reporting the different radionuclide imaging examinations ACC/AHA/ASNC practice guidelines [4], a report from the dealing with cardiac function. three major US organizations involved in this field. In this It has been our intention to present information specif- report, the main focus is on MPS, but assessment of LV ically adapted to European practice, based on evidence function is closely related to that. The ACC/AHA/ASNC from original scientific studies. Where more than one classifications I, II and III have been used to summarise the solution seems to be practised, and none has been shown to indications as follows: be superior to the others, we hope that we have succeeded in 1. Class I: Conditions for which there is evidence and/or specifically expressing this state of knowledge. general agreement that a given procedure (or treatment) The authors comprise scientists from many different is useful and effective countries, all with sub-speciality expertise in nuclear 2. Class II: Conditions for which there is conflicting cardiology. Every effort has been made to avoid conflicts evidence and/or a divergence of opinion about the of interest arising from non-academic and non-clinical usefulness/efficacy of a procedure relationships. Class IIa: Weight of evidence is in favour of usefulness/ efficacy List of contents Class IIb: Usefulness/efficacy is less well established by evidence/opinion 1. Clinical indications 3. Class III: Conditions for which there is evidence and/or 2. Radiopharmaceuticals and dosimetry general agreement that the procedure is not useful or 3. Acquisition of radionuclide ventriculography and effective and, in some cases, may be harmful. Such gated perfusion imaging indications are not discussed in the present guideline 4. Right ventricular ejection fraction Levels of evidence for individual class assignments are 5. Left ventricular ejection fraction designated as: 6. Left ventricular volumes 7. Left ventricular regional function – A = data derived from multiple, randomised, clinical 8. Left ventricular diastolic function trials 9. Physics and software – B = data derived from a single, randomised trial or 10. Reference values from non-randomised studies 11. Report and image display – C = consensus opinion of experts Level A is rarely available for diagnostic imaging and level B sometimes; hence, level C is most often applied. In the present guidelines, emphasis has been laid on the presentation of evidence-based data with direct references 1. Clinical indications to original papers. Clinical indications may often depend on several local factors such as availability, experience, Introduction traditions, reimbursement, risk of complications, logistics, etc. Furthermore, new modalities or development within a Assessment of left ventricular (LV) function and volumes is modality [gating of MPS, cardiac CT, contrast MRI important for prognostification, being very powerful predic- (cMRI), echocardiography, plasma atrial and brain natri- tors of long-term outcome after acute myocardial infarction uretic peptides (ANP and BNP)] may have a great impact (MI) [1, 2]. The information obtained to that obtained by on the clinical indications for alternative techniques. The ungated myocardial perfusion scintigraphy (MPS) by the most important indications are listed in Table 1. addition of gating has been demonstrated in several studies to be of high clinical value. The assessment of the function of the right ventricle (RV) is recognised to be important in Prognosis after acute MI with ST elevation subgroups of patients including arrhyhmogenic RV, in lung transplant candidates, and after MI, possibly including RV The prognosis of patients after ST elevation acute myocar- infarction, with high prognostic value