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Evaluating Cardiovascular Diseases with Cardiac SPECT and PET

Jeffrey Kempf, MD Gabrielle LaCroix, RN, CCRN. Evaluating Cardiovascular Diseases with Cardiac SPECT and PET. Nuclear Cardiac Stress Testing. Stress Test Options. ETT (EST / Regular) Bruce protocol ETT with Myocardial Perfusion Imaging(TST) Pharmacological Stress Dipyridamole (Persantine )

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Evaluating Cardiovascular Diseases with Cardiac SPECT and PET

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  1. Jeffrey Kempf, MD Gabrielle LaCroix, RN, CCRN Evaluating Cardiovascular Diseases with Cardiac SPECT and PET

  2. Nuclear Cardiac Stress Testing

  3. Stress Test Options • ETT (EST / Regular) Bruce protocol • ETT with Myocardial Perfusion Imaging(TST) • Pharmacological Stress • Dipyridamole (Persantine ) • Adenosine • Dobutamine Stress ECHO: Exercise Dobutamine

  4. ACC/AHAExercise Guidelines • ACC/AHA statistics 1:2500 can experience MI or death. • Perform only with appropriate indications and considerations • Requires supervision by trained physician or individual who meets ACC/AHA competency guidelines

  5. Exercise Stress Test • Indications • Diagnose suspected CAD in patients with chest pain(atypical /typical) and normal EKG • Assess long term-risk in patients thought to be at intermediate /high risk for significant CAD • Evaluate suspected arrhythmias • Assess functional ability • Evaluate effectiveness of medical/surgical therapy

  6. Absolute Contraindications • Recent AMI (within 48 hrs)-RWJUH 4 days • Unstable Angina • Uncontrolled arrhythmias • Severe symptomatic aortic stenosis • Uncontrolled symptomatic CHF • Acute pulm embolus/pulm infarction • Acute aortic dissection/aneurysm • Uncontrolled HTN

  7. Relative Contraindications • Left main disease • Mod stenotic valve disease • Electrolyte abnormalities • Severe arterial HTN (sys BP>200mm Hg, dias >110mm Hg) • Tachy/Brady arrhythmias • HCM or LVOT obstruction • Acute DVT • CVA within 3 months • Inability to adequately exercise • Acute systemic illness (pneumonia, severe anemia, infections)

  8. EKG Exclusion Criteria Resting EKG abnormalities which render interpretation inconclusive and nuclear stress would be indicated. • Baseline ST segment depressions > 1mm • Digoxin • WPW • Left Bundle Branch Block • PPM • EKG criteria for LVH

  9. Exercise Procedure(Bruce Protocol) • Goal 220-age= 100% MPHR, need 85% for diagnostic study. • Low-level or Modified Bruce: Goal 75% MPHR or symptom limited. • NPO for 3 hours • Must be able to walk treadmill • Notify if ICD present • No smoking ( no nicotine patches) • Hold beta blockers, nitrates (check with MD) • Comfortable clothing/shoes

  10. Bruce Protocol

  11. Indications for termination of test Absolute • Drop in sys BP of >10mm Hg from pre-test standing BP despite increase in workload with ischemic evidence • Moderate to severe angina • Sustained VT • ST elevation > 1mm in leads without diagnostic Q waves • Subjects desire to stop • Dizziness, near syncope, ataxia • Technical difficulties with EKG/BP • Signs of poor perfusion (pallor, cyanosis)

  12. Relative • Drop systolic BP > 10mm Hg despite increase workload without evidence of ischemia • ST depression ≥ 2mm horizontal/downsloping • Arrhythmias: multifocal PVC’s, triplets, tachy/brady arrhythmias • Fatigue, leg cramps, SOB, wheezing • New BBB or IVCD • HTN: sys > 250mm Hg, dias >115mm Hg

  13. ST Depression -Represents subendocardial ischemia -Abnormal >1mm horizontal/downsloping at .08sec past “J” point.

  14. Case: 48yr M R/O ACS 100%MPHR/10 min Rest EKG Peak Exercise

  15. Myocardial Perfusion ImagingSPECT • Indications • Detects presence/location/extent of myocardial ischemia in patients with R/O ACS • Risk stratification after ACS • Identify fixed defects, evaluate EF and viability • CP with abnl EKG’s (LBBB, PPM, LVH, NSSTW changes) • Equivocal ETT • Inability to exercise (pharmacological stress)

  16. MPI Radiopharmaceuticals • Thallium 201 • Technetium–99m • Sestamibi (Cardiolyte) • Tetrafosmin (Myoview) • Dual Isotope • Thallium injected for resting images • Tech -99m injected at peak stress • Resting Thallium -utilized to assess viability(no stress)

  17. ThalliumMPI Prep MI ruled out by cardiac markers NPO 6-12 hrs, NO CAFFEINE 24 hrs Wgt. <350 lbs. Consent IV access (peripheral preferred) No nuclear scans 24 hrs.(V/Q, bone) Be able to lie flat with hands behind head for 15 mins. x 2 Must be able to walk treadmill Notify if ICD present Pregnancy test for premenopausal women

  18. PHARMACOLOGICAL MPI • Indications: inability to exercise, abnl EKG (LBBB, PPM/ICD), risk stratification • Dipyridamole(Persantine)-indirectly causes coronary dilatation by blocking adenosine receptor sites. • Infused over 4 min, isotope at 7-9 min or hemodynamic response • Adenosine- potent vasodilator • Infused over 4 min, isotope at 2 min • Low level exercise diminishes side effects

  19. CONTRAINDICATIONS • Asthma/Severe COPD (can induce bronchospasm) • Hypotension • Recent CVA (within 30 days) • NY HA Class IV CHF SIDE EFFECTS • Chest Pain • Headache • Flushing • Nausea • Transient asystole & heart block(Adenosine)

  20. Dipyridamole/Adenosine prep • NPO 12 hours (No Caffeine for 24 hrs) • No methylxanthines(bronchodilators) • Actual wgt. (drugs are wgt. based!) • Systolic BP>95mm Hg • No oral dipyridamole • Hold beta blockers • Use with caution: migraines

  21. DOBUTAMINE • + Inotropic effect, increases myocardial O2 demand • Prep: same as ETT (no beta blockers, ICD off, etc) • Infuse 5-40 mcg/kg/min over 15 min • Goal to achieve 85% MPHR (atropine given 35% time) • End points same as ETT( EKG changes, CP, HTN etc.) SIDE EFFECTS • HTN • Chest pain • Arrhythmias(PVC’s 15%, SVT/Atrial 8%, NSVT 4%) • Palpitations/Anxiety

  22. SPECT MYOCARDIAL IMAGES

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