NUCLEAR

CARDIOLOGY
 INDICATION FOR MPI
1. Evaluation of patients with chest pain or ischemic equivalent

- intermediate or high likelihood of CAD

- Low likelihood of CAD with uninterretable resting ECG or unable
to exercise
- Possible ACS or new or recent onset chest pain

2. Clinical situation or symptom other than ischemic equivalent

- Cardiac enzyme elevation in conjunction with chest pain and/or

ECG abnormalities
- Abnormal,equivocal or discordant stress testing by ECG or
other imaging modalities
- Evaluation of coronary stenosis of uncertain significance from CA
- Evaluation of new onset or newly diagnosed heart failure
3.Risk Stratification and Prognosis Assessment

- chest pain syndrome wih high pre-test likelihood of CAD

- Following myocardial infarction or ACS
- Monitoring effect of treatment
- Previous abnormal CA or stress imaging study
- Viability assessment in LV dysfunction
- Undergoing non cardiac surgery with an intermediate or high
likelihood CAD

4. Possible Indication For Asymptomatic Patients

- Intermediate or high absolute 10 year risk of cardiac event based

on pre-test CAD risk factors
- Diabetes and evidence a diabetic complication,prolonged duration
of diabetes or additional CAD risk or female with diabetes
- Calsium Agatston Score of >400 or >100 in diabetes patient
- CKD (GFR < 30ml/min)
- Troponin elevation without evidence ACS
- Syncope with intermediate to high risk pre-test likelihood CAD
 HIGH RISK CAD
PATIENT PREPARATION — KEY ISSUES FOR REFERRING CLINICIANS

• Anti-anginal medication, especially beta blockers, should ideally be ceased for

up to 48 h prior to testing. This is particularly important for an exercise or

dobutamine protocol. In occasional prognostic evaluations, a study can be

performed on medication.

• Patients should cease all caffeine (or similar) intake 24 h prior to study. This

will allow a dipyridamole or adenosine protocol to be performed, even

unscheduled. Caffeine will block adenosine receptors and may result in a false-

negative study.
• Asthma can be aggravated by dipyridamole and adenosine, which may be
contraindicated. Dobutamine can be used instead. Patients with COPD without
bronchospasm may still be suitable for dipyridamole and adenosine testing.

• The patient should always come prepared for exercise (which may be combined
with pharmacological studies to improve sensitivity and image quality).

• The study may involve two sets of imaging, possibly even a 2 day protocol, so
that ischaemia can be evaluated by looking for a reversible defect.

• If a LBBB or paced rhythm is present, a dipyridamole or adenosine protocol is

often used. Higher heart rates (such as those with exercise or dobutamine) will
increase the likelihood of a false-positive reversible septal defect in these patients
Anterior view of the chest from a set of 64 projection images of
a SPECT MPI study depicting normal biodistribution of 99mTc-sestamibi
MYOCARDIA PERFUSION IMAGING/MPI
STRESS AND REST TEST
TC-99M SESTAMIBI SPECT IMAGES
STRESS

REST

STRESS

REST

STRESS

REST
SEMI-QUANTITATIVE PERFUSION ANALYSIS (POLAR
MAPS)
Perfusion (rest and stress 99mTc perfusion imaging)

Overview:

• Image quality (good or with technical limitations due to:

patient motion, dose extravasation, body habitus of the

patient, attenuation artefacts, etc.)

• LV size (rest LV size and transient cavity dilation if present);

• LV hypertrophy;

• RV size and tracer uptake;

• Lung uptake.

• Defect description:

Size; • Severity; • Location; • Reversibility.

Ventricular function

• Segmental wall motion assessment (visual);

• Wall thickening (visual);

• RV function (visual);

• Post-stress/rest LVEF (recommended);

• Rest LVEF only (optional for 1 day protocol);

• LV volumes (optional)
CASE I : DIAGNOSIS RCA ISCHEMIA

Myocardial Perfusion study with 99m Tc-sestamibi from 67 year old man with
Atypical angina (abdominal discomfort at stress) and normal ECG.

Stress : There is perfusion defect involving the inferior and inferolateral walls,
which normalizes almost completely at rest
Rest : Some uptake deficit is still present ,probably due to diaphragmatic
attenuation,which is more common in men.

S/ Reversible defect representing ischemia in the inferior and inferolateral walls

In the territory of the right coronary artery (RCA)

Coronary Angiography revealed , a critical stenosis of RCA  PTCA

CASE I
SA

STRESS

REST

VLA

HLA
Myocardial Perfusion study with 99m Tc-sestamibi from 67 year old man
with Atypical angina (abdominal discomfort at stress) and normal ECG

 Stress : There is perfusion defect involving

the inferior and inferolateral walls,which
normalizes almost completely at rest

 Rest : Some uptake deficit is still

present ,probably due to diaphragmatic
attenuation,which is more common in men

 S/ Reversible defect representing ischemia

in the inferior and inferolateral walls In the
territory of the right coronary artery (RCA)

 Coronary Angiography revealed , a critical

stenosis of RCA  PTCA
CASE II : DIAGNOSIS AND STRATIFICATION

A 56 year old woman with diabetes and history of dyspnoe and equivocal exercise
ECG.

Stress test with pyridamol : There is a perfusion defect seen at mid-portion of anterior
wall (mid ant,mid anteroseptal,mid anterolateral)

Rest test : defects resolve completely at rest

S/ - Reversible defect representing ischemia in mid portion of anterior wall

in the territory of a diagonal branch of LAD artery
- TID (+)

Coronary angiografi: mutiple lesions in LAD,LCx and distal RCA

TID (+)  high risk cardiac events  (+) multivessel disease
CASE II

STRESS

REST
CASE II : DIAGNOSIS AND STRATIFICATION

A 56 year old woman with diabetes and history of dyspnoe and equivocal exercise ECG.

 Stress test with pyridamol : There is a

perfusion defect seen at mid-portion
of anterior wall (mid ant,mid
anteroseptal,mid anterolateral)

 Rest test : defects resolve completely

at rest

 S/ - Reversible defect representing

ischemia in mid portion of anterior
wall in the territory of a diagonal
branch of LAD artery
- TID (+)
CASE III : ISCHEMIA AFTER PTCA

A 54 year old man with previous PTCA to the LAD 2 years previously, who
Presented with shortness of breath and chest discomfort after walking 200 m

Stress test : A perfusion defect is seen at apex,apiko inferior and mid inferior
(inferior wall)
Rest : A perfusion defect normalizes at rest

S/ Reversible ischemia defect in the territory of the LAD and RCA

MPI indication : to detect possible restenosis and/or progression of CAD

involving different territory
CASE III
Case IV

A 54 year old man with prevous myocardial infarction

Stress test with dypiridamol: A large perfusion defect is seen at the anterior,
anteroseptal and apical walls
Rest test after nitrates : There is no significant change between stress and rest
no significan associated ischemia or evidenve viability
in the infarct area

S/irreversible defect at the anterior,anteroseptal and apical walls with no viability

in the infarct area

The patient was not sent for cathetherization but giving maximum medical therapy
With cardiac transplantation to be eventually considered after a follow up period.
CASE IV
CASE V . VIABILITY STUDY

Myocardial perfusion study with 99mTc-sestamibi at rest (upper row) and

after nitrates (bottom row) in a 78 year old man with previous myocardial infarction
and heart failure

• The rest images show extensive perfusion defects at the posterolateral and
inferior walls, showing significant improvement after nitrates (although laterobasal
regions show little change). There is also a small anteroseptal area with the same
findings.

• The result is consistent with the presence of viable myocardium in most parts of
the affected areas, thus with potential of recovery after revascularization.

Myocardial viability studies are important in patients with heart failure and
coronary heart disease, in order to identify patients in whom revascularization
(either coronary artery bypass graft or PTCA) could result in functional improvement.
 REST

NITRAT
AUGMENTED
 PET Myocardial Viability imaging
 Primary metabolic substrate of normally perfused and
oxygenated myocardial  long chain fatty acids (70%)
and 20% fulfill by glucose

 Under condition of ischemia  switch substrat metabolism 

glucose anaerobic metabolism to maintain myocardial needs

 Identified chronically ischemia but viable miokardium 

hibernating miokardium

 A fixed defect on PET or SPECT MPI  scar or hibernation

 both with motion dysfunction

 Scar  irretrievable/dead myokardium

 Hibernating myocardium  chronically ischemia  still viable
revascularisation procedures
hibernating myocardium  can not use oxidative metabolism 
lack oksigen  switch anaerob metabolism glucose  viability
can detect by 18F-FDG + uptake FDG

A. SPECT MIBI B. 18F FDG PET C.FUSED

FDG PET

SESTAMIBI SPECT
NON CORONARY DISEASE STATE
 Valvular Disease
perfusion defect (+) without evidence of CAD
- mitral valve prolapse
- valvular aortic stenosis
 reduced perfusion gradient in coronary arteri
because of tight aortic stenosis
 angina like symptom
- aorta regurgitation  defect localized to the apex
of ventricle

 Left Bundle Branch Block (LBBB)

- nondiagnostic ECG stress testing  often sought
CAD from MPI  reversible defects in septal or
anteroseptal during stress testing  absence
demonstrable CAD
- asynchronous septal relaxation  out of phase with dyastolic
coronary filling  septal diminished perfusion

- Stress induced septal defect  LBBB directly related to

increase heart rate in stress exercise and dobutamin 
pharmacology stress with adenosin and dypiridamol  produces
no significant increase heart rate  useful alternatif  reduces
false positive

 Hypertensive Myocardial Hypertrophy

 RADIONUCLIDE IMAGING OF
CARDIAC FUNCTION

 Information about ventricular function  detection and

diagnosis cardiac problem and management patients
known with heart disease

 Assess both right ventricle and left ventricle pump performance

at rest,stress and insight intracardiac and cardiopulmonal
dynamics

 Radionuclide test for ventricular function : GSPECT,FP-RNA,

Equilibrium – RNA/MUGA,SPECT E-RNA
 First Pass Radionuclide Angiography (FP-RNA)

Imaging is undertaken during the initial rapid transit from

Intravenously bolus radioactive through lungs,cardiac and
Great vessels

 Equilibrium radionuclide Angiography

Image of cardiac blood pool obtained after radiopharmaceu

tical has equilibrated in the intravascular space  gated
Blood pool ventriculography/multi gated acquisition (MUGA)