DISCUSSION

CARDIAC NUCLEAR
IMAGING

Presented by:
dr. Ahmad Sufyan
Hiswandi

Supervisor:
dr. Irmarisyani, SpJP(K)
dr. Fritz Alfred Tandean, SpJP(K)
 Outlines
SPECT & PET
are the primary nuclear cardiology techniques

 Introduction
 Basic Principles of Nuclear Imaging
 The principles of Single Photon Emission Computed Tomography (SPECT)
imaging& Positron Emission Tomography (PET) imaging
 Imaging protocols
 Methods to reduce radiation dose
 Systematic scan interpretation
Introduction
 Nuclear cardiology is a specialized field within cardiology that uses
non-invasive imaging techniques to evaluate the function and structure
of the heart
 In 1957, Hal O. Anger’s, pioneer of nuclear medicine, develop the
gamma camera enabled heart imaging using gamma rays with
radiotracers uses
 Nuclear cardiac imaging constitutes the reference technique for non-
invasive evaluation of myocardial perfusion, and has become one of the
most frequently performed imaging modalities for the functional
assessment of patients with ischemic heart disease worldwide
 Over the past two decades, novel radiotracers, software improvements,
instrumentation advances, and personalized low radiation dose
protocols have transformed nuclear cardiology
Principle of Nuclear Medicine
 Atoms  the smallest building block of
matter (approximate size: 10− 10m)
 Consist of protons, neutrons, and
electrons
 The number of electrons = the number
of protons in a neutral atom
 K shell (inner to nucleus)  highest
binding energy
 Proton and neutrons in the nucleus also
 arranged in different energy levels
 Energy is released when an electron
drops from a outer shell to fill the
vacancy of a inner shell 
electromagnetic radiation  photon
 Isotopes  nuclides with different
 number of neutrons
Photon which emitted stable and
from electron 
radioactive
X-ray
 Photon which emitted from nucleus
(proton and neutron)  Gamma Ray
Principle of Nuclear Imaging
Radioactive Radiopharmaceutic
Isotopes als
Isotopes are forms of atoms Compounds that contain
 same number of radioactive isotopes  used
protons but different in nuclear imaging
number of neutrons procedures

Radioactive isotopes Attached to biological

(radionuclides) molecules (glucose, water,
or compounds) that
unstable nuclei and will naturally accumulate in
undergo decay to reach specific tissues of the body
stability
injected into the patient's
emit radiation (gamma rays body
or positron rays) which can
be used to create images isotopes decay

detected by SPECT or PET detected by SPECT or PET

SPECT & PET
The Principles of SPECT Imaging
Conventional
 Uses oneSPECT
or two detector heads mounted on a
rotating gantry to acquire 2D or 3D images (fig. A-B)

 Gamma rays emitted from radiotracers are detected

by a scintillation crystal, which converts energy into
light. The light is then converted into an electronic
signal by photomultiplier tubes (fig. C)
C
 Collimators are used to limit the acceptance of high-
energy photons traveling at narrow angles, helping
to provide clearer 2D images.

 Image quality is largely determined by the number

of photons detected, with attenuation from tissues
(especially in obese patients) reducing the number
of photons that reach the detector, affecting the
final image quality.
The Principles of SPECT Imaging
Novel SPECT
 FeatureScanner
improved gantry designs, including
cardiofocal or 360-degree detector geometries and
the use of semiconductor detectors.

 These innovations increase sensitivity and spatial

resolution by simultaneously acquiring tomographic
images over 180° or 360°, unlike conventional
scanners that rotate to collect multiple 2D images.

 The novel designs also enable dynamic imaging and

myocardial blood flow quantification, which is not
possible with conventional SPECT scanners.

 With these scanners, patient motion is easier to

detect, and incomplete scans can still be
reconstructed, providing a more robust imaging
process.
The Principles of PET Imaging
 Uses positron-emitting radionuclides that emit
positrons. Positrons collide with electrons,
producing two high-energy gamma rays (511
keV).

 Does not use lead septa, increasing count rate

but reducing spatial resolution. The 3D design
allows for faster imaging and lower
radiotracer doses.

 Uses solid-state detectors with silicon

photomultipliers for faster imaging and lower
doses.

 Correction is necessary due to the effect of

body tissues that block gamma rays, typically
using CT transmission images.

 PET is more sensitive without a physical

collimator but requires attenuation correction
for optimal image quality.
The Principles of PET Imaging
Hybrid Imaging
Refers to the assessment and combination of two imaging data sets  co-registered by spatial
superposition  contribute to the image information
(derived from various modalities: SPECT, PET, MRI, CT and echocardiography)

The combination of PET and SPECT with CT is

SPECT/ most established in daily clinical routine:
(1)Excellent image quality and high diagnostic

CT
PET/CT
accuracy of the state-of-the-art multi slice CT
scanner
(2)Low radiation burden of modern cardiac CT
acquisition protocols

PET/MR SPECT: non-uniform photon

attenuation occurs through
inhomogeneous density of Integrated to CT system for
different structures in and ATTENUATION
around the chest CORRECTION
Nuclear Imaging in Ischemia
Cascade
2024 ESC Guidelines for the Management of
Chronic Coronary Syndromes
Myocardial Perfusion Imaging

Normal
Myocardial
Perfusion

Abnormal
Myocardial
Perfusion
Radiotracers
Radiation Dose
SPECT Tracers 99m
Tc

PET Tracers 13
N
Patient Preparation
1. Fasting at least 3 hours prior to testing. 6. 12-lead ECG will be recorded every minute
2. Avoid consumption products containing during the adenosine infusion (4 to 6 minutes).
methylxanthines, caffeine-containing drug 7. BP should be monitored every minute
products and theophylline for at least 12 hours during infusion and 3 to 5 minutes into
prior to the testing. recovery or until stable.
3. Dipyridamole should be withheld for at least 8. Adenosine infusion should be given at a rate of
48 hours (2 days) prior to adenosine 140 mcg/kg/min for 3 minutes followed by
administration. the injection of the radiotracer. The infusion
4. An infusion pump is required for adenosine should be continued for another 3 minutes.
to be administered at a constant infusion rate. 9. For patients deemed to be at a higher risk for
5. An IV line with a dual-port Y-connector is complications adenosine infusion may be
required for the injection of the radiotracer during started at a lower dose (70 to 110
adenosine infusion. mcg/kg/min).
Imaging Protocols
Myocardial Perfusion Scintigraphy (MPS)
• Assess the functional significance of known or suspected coronary artery stenosis
• Reveals differences in perfusion between the myocardium supplied by normal
coronary arteries and that by stenosed coronary arteries
• Resting conditions  the MBF remains relatively unchanged within a wide range of
severity of coronary stenosis and begins to decline with stenosis of >80–85%
• In contrast  stenoses of >~40%  apparent under hyperaemic conditions
• Stress testing  induce maximal or near-maximal coronary hyperaemia

Incremental dynamic exercise increases the MBF by

Exercise
provoking coronary vasodilation secondary to a
Stress
progressive increase in myocardial oxygen demand.

Dipyridamole, adenosine, and regadenoson exert their

Vasodilator primary coronary vasodilator effect by binding to
Stress adenosine A2A receptors expressed on the surface of
coronary arteriolar smooth muscle cells

Dobutamine stress increases myocardial oxygen demand,

Dobutamine
and subsequently the MBF, in a dose-dependent fashion
Stress
through its inotropic (low dose,
Exercise Stress
Exercise devices Exercise for myocardial perfusion
scintigraphy

Regardless of the protocol used, the heart The aim of the test is to achieve adequate
rate, blood pressure, and a 12-lead ECG are coronary hyperaemia. A combined end point
recorded at baseline and then every 2–3min of maximal or near-maximal heart rate (HR),
throughout the test adequate workload, and symptoms should be
used
Pharmacological Stress
Adenosin Regadenos Diprydamol
Dobutamine
e on e
Binds non- Selective Lipophilic • Synthetic dopamine
selectively to adenosine A2A pyrimidine base analogue with a
all adenosine receptor agonist that increases half-life of
receptors endogenous approximately 2min
adenosine by • Potent β1
blocking its adrenergic receptor
cellular reuptake agonist with weak
and breakdown β2 and α1 activity
Half-life <10 Administered as Given as an IV Increases myocardial
s, hence the a single injection over contractility
need for intravenous (IV) 4min, with tracer (inotropic effect) and
continuous dose of 400 μg, administration 3– heart rate
infusion and given as a 4min later, half- (chronotropic effect)
rapid injection life of in a dose-dependent
over at least 10 approximately manner
s followed by 30min.
saline flush and
tracer injection
10–20 s later
Injection Reaches peak After 3min on a
between the effect within 30 maximal dose of
third and s, with coronary 40μg/kg/min, which
fourth minute hyperaemia results in a significant
of infusion lasting for increase in heart rate
approximately and cardiac output
2.5min. from the baseline,
the tracer is
administered
Indication & Contraindication
Protocols Indication
• To assess the functional significance of known or suspected coronary artery disease (CAD) in patients who are able to
exercise appropriately
Dynamic Stress
• Preferred modality of stress in patients with suspected ischaemia of non-CAD aetiology
• As a supplement to vasodilator stress for the purpose of improving image quality and tolerability to stress
Vasodilator • Contraindication to exercise or inability to complete an exercise test adequately
Stress • LBBB or ventricular pacing rhythm on resting ECG
Dobutamine
• Contraindication to vasodilator stress
Stress Contraindication to vasodilator
stress
• Acute or unstable coronary
syndrome. Vasodilator stress may
be considered after 24–48h of an
uncomplicated event in the
absence of chest pain

• Active bronchospasm at
presentation

• Second- or third-degree AV block,

or sinoatrial disease, in the
absence of a functioning
pacemaker

• Hypotension with systolic blood

pressure
SPECT Protocol
STRESS FIRST TWO-DAY PROTOCOL
• Recommended for patient with obesity of young
patient
• Use equal dose of radiotracer each day
• Stress imaging performed first on Day 1,
• rest imaging is only performed on Day 2 if abnormal
result was found on stress imaging
• Provide the lowest possible radiation dose and
optimal image quality

PET Protocol
Systematic Scan Interpretation
Image Image Image Review and
Quality Display Interpretation
A systematic review of images will improve diagnostic accuracy of scan interpretation and
intra / interreader variability

Standard Imaging Display

Vertical long-axis (VLA): Short-axis (SA): Horizontal long-axis (HLA):

anterior, apex, and inferior walls anterior, lateral, inferior, and septal walls septum, apex, and lateral walls
Myocardial Segmental Model
Images Review, Reporting & Interpretation
Qualitative, semiquantitative and quantitative The presence of location and
evaluation perfusion defect
Indicatio Percentage of
Type Criteria
n Myocardium
Stress-induced
abnormality (>2.5
Present only on
SD below normal)
Reversib stress images Myocardial
with a resting pixel
le compared to rest ischemia
density 2.5 SD higher
images
than stress or within
Scan interpretation starts with a visual evaluation of rest,
2.5 SD of normal
Visual stress images for LV size, right ventricular (RV) size, and
tracer uptake. Same reduction in
Present and
Made a count for: counts (>2.5 SD
unchanged Myocardial
Semiquantitati 1. The sum of the stress scores (SSS) Fixed from normal)
between stress scarring
ve 2. The sum of rest score (SRS) between stress and
and rest
3. Summed difference score (SDS) rest

Myocardial blood flow and myocardial flow reserve (MFR) Ischemia

Quantitative Mixed/
Present at rest, superimpos
Partially
The extent of perfusion defect = the amount of abnormal and worsened on ed
Reversib
myocardium territory stressType
imagesof stress,
upon protocol and
le
tracer
scarring
Software Analysis:
4DM (17 myocardial segment), Cedar Sinai Protocol (20 myocardial segment), EcTB (Emory
cardiac toolbox
MPI Interpretation
ISCHAEMIC

INFARCT

• Ischemia  normal perfusion

at rest, stress induced
perfusion abnormality
(reversible)

• Infarct  perfusion
abnormality at stress and rest
(fixed)
MPI Interpretation
Stress Rest Confirmed
Study Study by Visual Interpretation
Score Score Analysis

Reversible defect
1/2/3/4 0 Yes (inducible ischemia,
viable)
Partially reversible
1/2
defect
2/3/4 (other Yes
(inducible ischemia,
than 0)
viable)
Mild fixed defect
1 1 Yes
(viable)

Moderate fixed
2 2 Yes
defect (viable)

Severe fixed defect

3/4 3/4 Yes
(non viable)
Methods to Reduce Radiation Dose
Latihan Kasus
 CASE 1

Ny. EM / 73 th
Obs chest discomfort,
hypertension,
uncontrolled T2DM
 CASE 2
[Link] / 74 th
• Post CABG 11/05/16, DMT2
• CVI ringan kedua tungkai
• Aritmia on TMT
 CASE 3
[Link] / 72 th
• CAD 2VD s/p PPCI 1 stent at LAD Des
2023,
• Hipertensi, HHD, LVEF 64%,
• Mild AR due to calcified NCC and
LCC
THANKYOU