Eur J Nucl Med Mol Imaging (2012) 39:160–164
DOI 10.1007/s00259-011-1923-9
OCCASIONAL SURVEY
Myocardial perfusion scintigraphy in Europe 2007: a survey
of the European Council of Nuclear Cardiology
Eliana Reyes & Susanna Wiener &
S. Richard Underwood &
on behalf of the European Council of Nuclear Cardiology
Received: 20 April 2011 / Accepted: 17 August 2011 / Published online: 6 September 2011
# Springer-Verlag 2011
Abstract
Purpose This is the second of a series of surveys designed
to assess myocardial perfusion scintigraphy (MPS) practice
in Europe.
Methods Data were collected from 258 centres in 18
countries. The number of MPS studies per million population
(pmp) was estimated assuming that the nonresponding centres
performed either no studies (lower estimate) or the same
number as the responding centres (upper estimate).
Results The responding centres served 24% of the popula-
tion of their countries. The total number of noncardiac
nuclear medicine studies was between 2,160 and 8,000
studies pmp. The total number of MPS studies was between
529 and 2,293 pmp. The median number of MPS studies
per centre was 571 per year with 57% performing fewer
than 500 studies per year and 23% of centres performing
fewer than 250 studies per year. There was significant
variation between countries, with higher numbers of MPS
studies (lower limit of estimate above the mid-range of all
countries combined) in Austria, Denmark, Hungary, Portugal
and Slovenia, and lower numbers (upper limit of estimate
below the mid-range of all countries) in Finland, Norway,
Spain and Switzerland. The ratio of MPS to coronary
Electronic supplementary material The online version of this article
(doi:10.1007/s00259-011-1923-9) contains supplementary material,
which is available to authorized users.
E. Reyes : S. R. Underwood
Nuclear Medicine Department, Royal Brompton Hospital,
Sydney Street,
SW3 6NP London, UK
S. Wiener (*)
European Council of Nuclear Cardiology,
Hollandstrasse 14 / Mezzanine,
A-1020 Vienna, Austria
e-mail: ecnc-office@vereint.com
URL: http://www.ecnc-nuclearcardiology.org
angiography to revascularization procedures was 0.9 to 2.2
to 1. Pharmacological stress was used in 57% and technetium-
99m-labelled tracers in 88% of studies. ECG gating was
performed in 74% of studies and attenuation correction in
22%.
Conclusion MPS utilization in Europe remains low compared
with coronary angiography although there has been a 21%
increase in the number of studies pmp in centres that reported
in both 2005 and 2007. Pharmacological agents continue to be
the predominant form of stress. Despite the widespread use of
technetium-99m-labelled tracers, ECG gating is not univer-
sally performed. As in the 2005 survey, imaging aids such as
attenuation and motion correction and prone imaging are not
commonly used.
Keywords Myocardial perfusion scintigraphy . Survey .
Coronary artery disease
Introduction
Myocardial perfusion scintigraphy (MPS) is a robust nonin-
vasive imaging technique that provides valuable diagnostic
and prognostic information in patients with known or
suspected coronary artery disease [1, 2]. Utilization of MPS
has increased substantially over the past decade, but growth
rate and trends vary across countries. A previous report
showed significant differences in practice within Europe [3].
We hypothesized that such differences would become less
apparent as clinical and procedural guidelines are increasingly
adopted and service provision becomes more homogeneous
within and between countries. Results from national and
international surveys such as this might also exert an effect,
albeit small, on practice. In 2005 we conducted the first of a
series of regular surveys designed to examine the scale and
nature of MPS practice within Europe and to provide a
Eur J Nucl Med Mol Imaging (2012) 39:160–164 161

reference guide for future service delivery planning [3]. We
report the results of the second of such surveys.
Methods
A full description of the methods used for data collection
and interpretation has already been published [3]. Briefly,
an internet-based survey of European centres known to
perform MPS was conducted. Information was obtained on
MPS studies performed in the calendar year 2007. The
survey contained only two obligatory questions concerning
the number of MPS studies performed in 2007 and the
population served by the MPS centre (see Electronic
supplementary material). The questionnaire clarified that
the numbers related to patient studies counting a stress–rest
study as a single study. There were a number of optional
questions concerning the numbers of other cardiac inves-
tigations performed and procedures used for MPS. To
minimize the effect of incomplete data collection, numbers
of MPS and other studies were corrected for the percentage
of each national population covered by the centres that
reported, assuming either that centres that did not report
performed no studies (lower limit of estimate) or that they
performed the same number of studies per million popula-
tion (pmp) as the centres that did report (upper limit of
estimate). The range between the lower and upper estimates
provided a measure of the precision of the data. It is
possible that centres that did not report performed more
studies than those that did, in which case the upper limit
would not be the maximum possible, but it was considered
a reasonable estimate.
Results
Questionnaires were returned by 258 centres in 18 countries
(Table 1). The reporting centres served 24% of the population
of their countries. For the first time since the 2005 survey,
centres from Belgium, France and Italy submitted data. In
contrast, no data or insufficient responses were received from
Israel, Poland and Turkey.
Nature of departments
Of the total of responding centres, 49% were teaching
hospitals, 31% were nonteaching hospitals, 7% were privately
funded hospitals, 9% had a different setting (mainly private
outpatient centres) and 4% were other hospitals (e.g. military
hospitals).

Table 1 Participating countries in the 2005 and 2007 surveys, with number of centres responding to the survey, MPS studies declared in 2007 by
those centres, country population and proportion of that population served by the centres

Country 2005 2007 Centres MPS studies declared in 2007 Country population (millions) Population served (%)

Austria x x 23 19,943 8.298 83.5

Belgium x 7 6,410 10.584 13.7
Czech Republic x x 13 8,188 10.287 44.7
Denmark x x 15 8,626 5.441 100
Finland x x 9 1,517 5.277 36.6
France x 14 22,939 63.392 9.3
Germany x x 30 16,933 83.315 15.7
Greece x x 7 12,361 11.172 37.9
Hungary x x 11 13,668 10.066 62.0
Italy x 16 28,166 59.131 14.8
Israel x
The Netherlands x x 5 8,013 16.358 10.3
Norway x x 14 3,643 4.681 62.6
Poland x
Portugal x x 6 13,766 10.599 31.3
Slovenia x x 4 3,110 2.010 99.5
Spain x x 14 9,425 44.475 19.0
Sweden x x 13 5,301 9.113 35.9
Switzerland x x 12 5,898 7.509 57.8
Turkey x
United Kingdom x x 45 35,214 60.817 38.6
162
Gamma cameras and scan activity
MPS studies were performed on a single gamma camera in
24% of centres, of which 75% were multiheaded tomographic
cameras. The remaining centres had at least two gamma
cameras with tomographic capability on at least one camera.
The total number of noncardiac nuclear medicine studies
reported was 965,967 for a population of 82,314,947, which is
between 2,160 and 8,000 studies pmp with the assumption
made for studies performed in the nonreported population.
The total number of MPS studies reported was 223,684 for a
population of 97,515,942, which is between 529 and
2,293 pmp. Figure 1 shows the numbers of MPS studies
pmp in each country. There was significant variation between
countries, with higher numbers of MPS studies (lower limit of
estimate at or above the mid-range of all countries combined)
in Austria, Denmark, Hungary, Portugal and Slovenia, and
lower numbers (upper limit of estimate below the mid-range
of all countries) in Finland, Norway, Spain and Switzerland.
In centres reporting numbers of coronary revascularization
procedures (percutaneous or surgical), the ratios of MPS
studies to coronary angiography procedures to revasculariza-
tion procedures were 0.9 to 2.2 to 1. The median number of
MPS studies per centre was 571 (interquartile range 253–
1,097). Over half of centres (57%) performed fewer than 500
studies and 23% of centres performed fewer than 250 studies;
12% of centres performed more than 2,000 studies (Fig. 2).
MPS referrals
The main indications for MPS were diagnosis of coronary
artery disease (56% of studies) followed by assessment of
known disease (39%) and of myocardial viability and
hibernation (5%). Most MPS procedures (82%) were per-
Fig. 1 Number of MPS studies
pmp by country. The lower limit
of each bar represents the num-
ber reported assuming centres
not reporting performed no
studies. The upper limit of each
bar is the extrapolated figure
assuming that the unreported
population had the same rate of
MPS studies as the reported
population. The length of the
bar is inversely proportional to
the percentage of the population
reported
Eur J Nucl Med Mol Imaging (2012) 39:160–164
formed on outpatients with 34% of total patients being
referred from centres other than the site performing MPS.
The majority of studies were requested by cardiologists (80%)
followed by noncardiac physicians (11%), primary care
physicians (5%) and surgeons (cardiac and noncardiac)
(4%). The median waiting time for a routine MPS study was
21 days (interquartile range 7.5–45 days) and for an urgent
MPS study 2 days (interquartile range 1–5 days).
Stress techniques
Pharmacological stress with either a vasodilator or dobutamine
was used in 57% of MPS studies (Fig. 3). Pharmacological
stress was the commonest form of stress in Austria, Belgium,
Denmark, Hungary, Norway, Portugal, Slovenia, Spain,
Switzerland and the UK, whereas dynamic exercise was the
commonest form of stress in the Czech Republic, Finland,
France, Germany, Greece, Italy, Sweden and The Netherlands.
Vasodilator (dipyridamole or adenosine) stress was combined
with exercise in 58% of the vasodilator studies.
MPS radiopharmaceuticals and imaging techniques
Technetium-99m-labelled agents were the commonest
radiopharmaceuticals used for MPS with technetium-99m
tetrofosmin and technetium-99m MIBI administered in
51% and 37% of studies, respectively. Thallium-201 was
administered in 11% of studies. Dual isotope imaging was
used in only 2% of studies. Of all technetium-99m MPS
studies, 59% were performed using a 2-day imaging
protocol, 13% using a 1-day rest–stress protocol and 28%
a 1-day stress–rest protocol.
MPS studies were acquired using single photon emission
computed tomography (SPECT) in 96% of centres. ECG-
Eur J Nucl Med Mol Imaging (2012) 39:160–164
Fig. 2 Histograms showing per-
centages of centres in relation to
the number of MPS studies
reported
gated acquisition was used in 74% of MPS studies.
Attenuation and motion correction were applied in 22%
and 13% of studies, respectively. Prone imaging either in
addition to supine or instead of supine imaging was used in
16% of centres.
MPS reporting
Of all studies, 67% were reported by a single specialist.
In 60% of all studies this was a nuclear medicine
physician, in 6% a cardiologist and in 1% a radiologist.
Of all studies, 33% were reported by a combination of
specialists. A cardiologist was involved in 23% of
studies. The majority of MPS studies were reported
from the computer screen alone (47%) or from both
computer and hard-copy (45%). There was a significant
reduction in the proportion of studies reported from
hard-copy alone (8% vs. 18% in 2005). In 70% of
studies the raw data was inspected alongside the
tomograms at the time of reporting.
Fig. 3 Percentages of MPS studies performed with each type of
cardiac stress test
163
Of all centres, 92% used a continuous colour scale in
order to assess myocardial tracer uptake (cool scale 60%,
rainbow 17%, other 15%). Grey scale was used in 8% of
centres, 4% used a discrete colour scale with banding, and
2% used a monochrome colour scale such as hot body. As
in the 2005 survey, more than one colour scale was used in
some centres. For the assessment of left ventricular
function, most centres (83%) used a continuous colour
scale (cool scale 63%, rainbow 7%, other 13%), 15%
used grey scale, 14% used a monochrome colour scale
such as hot body and 6% used a discrete colour scale
with banding.
Discussion
We have previously reported the first of a series of surveys
designed to characterize the practice of MPS in Europe [3].
As in the 2005 survey, the response rate varied between
countries, and the population covered by the reporting
centres in this survey was only 24% of the summed
populations of their countries. Despite this limitation, the
survey may act as a reference guide to current nuclear
cardiology practice in Europe.
Overall MPS activity
For the first time since the 2005 survey, data were obtained
from France, Italy and Belgium. In contrast, incomplete or
no data were obtained from Israel, Poland and Turkey. The
lower and upper estimates of the numbers of MPS studies
in 2007 were 529 and 2,293 pmp respectively, similar to the
2005 estimates [3]. These figures are relatively low and
there is a large range in the estimates, but it is likely that the
true value is nearer the upper than the lower estimate since
it is unlikely that the centres not included in the survey did
no studies. There is also evidence that the rates of MPS
studies are increasing since in centres that reported in both
164
2005 and 2007 the number of MPS studies rose from
1,584 pmp to 1,998 pmp, an increase of 21%. These
figures are likely to be the best estimate of changes
with time.
All of the figures continue to be lower than the level of
activity of 4,000 MPS studies pmp supported by the UK-
based NICE appraisal, which was based upon the ratio of
MPS to recommended numbers of revascularization proce-
dures [1, 2]. The ratio of 0.9 MPS to each revascularization
procedure is higher than in the 2005 survey when it was
0.6, possibly reflecting the high level of nuclear cardiology
activity in countries such as Belgium, which was not included
in 2005.
The methodology for estimating study numbers pmp
depended upon centres knowing the population that they
serve. Because referral patterns can be complex, some
centres may have had difficulty in estimating this number.
The questionnaire therefore provided guidance on how to
estimate the number from the national rate and the local
numbers of revascularization procedures, both of which are
usually well known.
It is useful to compare these findings with those of other
surveys. The number of MPS scans increased in Ontario,
Canada by 101% between 1997/1998 and 2005/2006,
which is an annual increase of approximately 13%
assuming linear growth [4]. In the US a 16% annual
increase between 2008 and 2014 has been predicted for
SPECT/CT [4]. Smaller increases have been reported in
European countries between 2005 and 2007 despite a net
decrease in the overall use of all SPECT imaging of
approximately 1% [4], but there was a decrease of 2.2% in
Germany between 2005 and 2009, possibly because of an
increase in competing imaging techniques, among other
factors [5].
Local MPS activity
The histogram of annual activity (Fig. 2) shows that 23% of
centres performed fewer than 250 studies, 57% performed
fewer than 500 and 12% performed more than 2,000.
Relevant procedure guidelines [6–8] do not state a minimum
number of studies to maintain competence, but professional
opinion suggests that fewer than 250 studies per year is not
ideal and that at least 500 per year is preferable [9].
Technical issues
As in the 2005 survey, dynamic exercise remained the
commonest single form of stress (43%). Pharmacological
Eur J Nucl Med Mol Imaging (2012) 39:160–164
stress in general accounted for the remaining 57% with
dipyridamole being the most common (28%). The percent-
age of vasodilator studies that were combined with dynamic
exercise increased from 49% in 2005 to 58% in 2007. This
increase is in line with procedure guidelines, which
recommend the combination in order to reduce the
incidence of vasodilator side effects.
The reported use of ECG gating was higher than in 2005
(74% vs. 65%), but this remains low considering that the
majority of MPS studies use technetium-99m-labelled tracers.
Likewise, quality-enhancing tools such as attenuation and
motion correction remain under-used.
Acknowledgments We would like to thank the staff of the centres
that returned information and, in particular, we thank the national
coordinators for helping to maximize returns (P. Aramugam, I. Balogh, P.
de Bont, G. Cantinho, L. Edenbrandt, P. Georgoulias, S. Graf, M. Kamínek,
G. Kravdal, D. Le Guludec, O. Lindner, C. Marcassa, M. Milcinski, A.
Muxi, S. Nielsen, J. Prior, H. Ukkonen, G. Zettinig). We thank Bristol
Myers Squibb Medical Imaging, Cardiovascular Therapeutics Inc, CIS Bio
International, Covidien Pharmaceuticals, GE Healthcare, Philips Medical
Systems and Siemens Medical Solutions for unrestricted grants.
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