Chronic stable angina myocardial perfusion scintigraphy: Difference between revisions

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{{Chronic stable angina}}
{{Chronic stable angina}}
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Associate Editor(s)-in-Chief:''' {{CZ}}; Smita Kohli, M.D.
 
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Associate Editor(s)-In-Chief:''' {{CZ}}; Smita Kohli, M.D.; [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan, M.B.B.S.]]


'''''Synonyms and keywords:''''' Myocardial perfusion imaging, MPI, myocardial perfusion scan, exercise myocardial perfusion imaging, stress thalium scan, nuclear stress test.  
'''''Synonyms and keywords:''''' Myocardial perfusion imaging, MPI, myocardial perfusion scan, exercise myocardial perfusion imaging, stress thalium scan, nuclear stress test.  
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*As a noninvasive, less expensive and readily available test at more centers, [[Chronic stable angina echocardiography|echocardiography]] is usually preferable method for this purpose.
*As a noninvasive, less expensive and readily available test at more centers, [[Chronic stable angina echocardiography|echocardiography]] is usually preferable method for this purpose.


==ACC / AHA Guidelines- Nuclear Stress Testing in patients Who Are Able to Exercise (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>==
==ACC / AHA Guidelines- Nuclear Stress Testing in patients Who Are Able to Exercise (DO NOT EDIT) <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>==
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===Class I===
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
'''1.''' Exercise myocardial perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in patients with an [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate pretest probability]] of [[CAD]] who have 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
'''1.''' Exercise myocardial perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in patients with an [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate pretest probability]] of [[CAD]] who have 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
:a. Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
:'''a.''' Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:b. More than 1 mm of rest [[ST depression]]. ''(Level of Evidence: B)''
:'''b.''' More than 1 mm of rest [[ST depression]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''2.''' Exercise myocardial perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in patients with prior [[revascularization]] (either [[percutaneous transluminal coronary angioplasty]] ([[PTCA]]) or [[coronary artery bypass graft]] ([[CABG]]). ''(Level of Evidence: B)''
'''2.''' Exercise myocardial perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in patients with prior [[Chronic stable angina revascularization|revascularization]] (either [[Chronic stable angina revascularization percutaneous coronary intervention(PCI)|percutaneous transluminal coronary angioplasty]] (PTCA) or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|coronary artery bypass graft]] (CABG). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''3.''' [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|Adenosine or dipyridamole myocardial perfusion imaging]] in patients with an [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate pretest probability]] of [[CAD]] and 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
'''3.''' [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|Adenosine or dipyridamole myocardial perfusion imaging]] in patients with an [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate pretest probability]] of [[CAD]] and 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
:a. Electronically paced ventricular rhythm. ''(Level of Evidence: C)''
:a. Electronically paced ventricular rhythm. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
:b. [[Left bundle-branch block]]. ''(Level of Evidence: B)''
:b. [[Left bundle-branch block]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


===Class IIb===
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
'''1.''' Exercise myocardial perfusion imaging and [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in patients with a [[Chronic stable angina assessing the pretest probability of coronary artery disease|low or high probability]] of [[CAD]] who have 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
'''1.''' Exercise myocardial perfusion imaging and [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in patients with a [[Chronic stable angina assessing the pretest probability of coronary artery disease|low or high probability]] of [[CAD]] who have 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
:a. Preexcitation ([[Wolff-Parkinson-White|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
:'''a.''' Preexcitation ([[Wolff-Parkinson-White|Wolff-Parkinson-White]]) syndrome. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:b. More than 1 mm of [[ST depression]]. ''(Level of Evidence: B)''
:'''b.''' More than 1 mm of [[ST depression]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''2.''' [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|Adenosine or dipyridamole myocardial perfusion imaging]] in patients with a [[Chronic stable angina assessing the pretest probability of coronary artery disease|low or high probability]] of [[CAD]] and 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
'''2.''' [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|Adenosine or dipyridamole myocardial perfusion imaging]] in patients with a [[Chronic stable angina assessing the pretest probability of coronary artery disease|low or high probability]] of [[CAD]] and 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
:a. Electronically paced ventricular rhythm. ''(Level of Evidence: C)''
:'''a.''' Electronically paced ventricular rhythm. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
:b. [[Left bundle-branch block]]. ''(Level of Evidence: B)''
:'''b.''' [[Left bundle-branch block]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''3.''' Exercise myocardial perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in patients with an [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate probability]] of [[CAD]] who have 1 of the following:
'''3.''' Exercise myocardial perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in patients with an [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate probability]] of [[CAD]] who have 1 of the following:
:a. [[Digoxin]] use with less than 1 mm [[ST depression]] on their baseline [[Chronic stable angina electrocardiography|ECG]]. ''(Level of Evidence: B)''
:'''a.''' [[Digoxin]] use with less than 1 mm [[ST depression]] on their baseline [[Chronic stable angina electrocardiography|ECG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:b. [[LV hypertrophy]] with less than 1 mm [[ST depression]] on their baseline [[Chronic stable angina electrocardiography|ECG]]. ''(Level of Evidence: B)''
:'''b.''' [[LV hypertrophy]] with less than 1 mm [[ST depression]] on their baseline [[Chronic stable angina electrocardiography|ECG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''4.''' Exercise myocardial perfusion imaging, [[Chronic stable angina exercise echocardiography|exercise echocardiography]], [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|adenosine or dipyridamole myocardial perfusion imaging]], or [[Chronic stable angina exercise echocardiography|dobutamine echocardiography]] as the initial stress test in a patient with a normal rest [[ECG]] who is not taking [[digoxin]]. ''(Level of Evidence: B)''
'''4.''' Exercise myocardial perfusion imaging, [[Chronic stable angina exercise echocardiography|exercise echocardiography]], [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|adenosine or dipyridamole myocardial perfusion imaging]], or [[Chronic stable angina exercise echocardiography|dobutamine echocardiography]] as the initial stress test in a patient with a normal rest [[ECG]] who is not taking [[digoxin]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''5.''' [[Chronic stable angina exercise echocardiography|Exercise or dobutamine echocardiography]] in patients with [[left bundle-branch block]]. ''(Level of Evidence: C)''}}
'''5.''' [[Chronic stable angina exercise echocardiography|Exercise or dobutamine echocardiography]] in patients with [[left bundle-branch block]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''}}


==Vote on and Suggest Revisions to the Current Guidelines==
==Vote on and Suggest Revisions to the Current Guidelines==

Revision as of 18:22, 25 August 2011

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [5] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [6]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Synonyms and keywords: Myocardial perfusion imaging, MPI, myocardial perfusion scan, exercise myocardial perfusion imaging, stress thalium scan, nuclear stress test.

Overview

In patients with baseline ECG abnormalities, myocardial perfusion test can be used to localize the region of ischemia. Thallium-201 and technetium-99m are the two radio-labeled agents that are frequently used for the assessment of myocardial perfusion. Myocardial uptake of thallium-201 chloride is directly proportional to the regional myocardial blood flow and is dependent on the presence of viable myocardium. In patients with known CAD, a normal thallium stress test without a perfusion defect is indicative of a benign process and associated with excellent prognosis. Patients with a normal thallium scan are at low risk for CAD and subsequent coronary angiography is indicated only if the patient has a high probabilty Duke treadmill score. Contraindications for thallium stress test include the presence of arrhythmia, acute myocarditis, severe aortic stenosis and acute MI within the past 2 days.

Stress Thallium-201 Test

SPECT images of myocardial perfusion showing a reversible perfusion defect in inferior and lateral walls(Note the defect present in stress but not in rest images)

Indication:

  • Myocardial perfusion scintigraphy with thallium-201 is frequently employed as a noninvasive test to evaluate abnormalities of myocardial perfusion in patients with established or suspected CAD.
  • Thallium images may be planar or tomographic (single photon emission computed tomography=SPECT). The latter are more accurate and are therefore used more frequently to assess the presence and extent of ischemic and infarcted myocardium.

Mechanism of benefit:

  • Myocardial uptake of thallium-201 chloride is proportional to regional myocardial blood flow and is dependent on the presence of viable myocardium.
  • During exercise, the magnitude of the increase in blood flow to the non-ischemic myocardial zones is greater than to the zones supplied by stenotic coronary arteries. Owing to this heterogeneous distribution of blood flow, the relative extraction of thallium by non-ischemic myocardium is greater than that by ischemic myocardium.
  • During exercise thallium testing, the isotope is administered intravenously during peak exercise, and stress images are obtained immediately after discontinuation of exercise. These images reveal a decreased uptake by the ischemic myocardium, creating a perfusion defect.
  • Redistribution images are obtained after 4 hours. Myocardium that was ischemic during stress but that is not ischemic at rest now extracts the isotope. Therefore, the perfusion defects during stress images are not observed in the rest images, and these reversible perfusion defects indicate the presence of viable myocardium.
  • If the perfusion defects in stress images persist in the rest images, that is, if the perfusion defects are fixed, the myocardium is usually necrotic or fibrotic.
  • A repeat injection of thallium and scanning 24 hours after stress can distinguish severely ischemic area from viable myocardium.

Sensitivity and Specificity:

  • In pooled analyses from multiple studies, exercise treadmill thallium myocardium scintigraphy has sensitivity for detecting CAD and specificity for excluding it of about 84% and 88%, respectively. The sensitivity approaches 90% with a quantitative computer-assisted analysis of the images without loss of specificity.
  • Considerable experience is required for the performance and interpretation of exercise thallium scintigraphy to achieve these high degrees of specificity and sensitivity.
  • Like the exercise ECG, thallium stress scintigraphy is less sensitive in the diagnosis of single vessel disease, particularly of circumflex coronary artery stenosis, than in multi vessel coronary artery disease.

Technetium-99m

  • Technetium-99m, a calcium analog with a higher photon energy and a shorter half life than thallium chloride, can be linked to a variety of agents.
  • Technetium-99m-sestamibi is an isonitrile compound that, like thallium, is taken up by the myocardium proportional to blood flow but in contrast to thallium does not undergo redistribution.
  • Indications:
  • Technetium-99m is used as a marker of myocardial perfusion.
  • Tomographic images with technetium-99m also allow images to be acquired on the first pass through the ventricle and can be used to assess the left ventricular ejection fraction.
  • As a noninvasive, less expensive and readily available test at more centers, echocardiography is usually preferable method for this purpose.

ACC / AHA Guidelines- Nuclear Stress Testing in patients Who Are Able to Exercise (DO NOT EDIT) [1]

“

Class I

1. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate pretest probability of CAD who have 1 of the following baseline ECG abnormalities:

a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: B)
b. More than 1 mm of rest ST depression. (Level of Evidence: B)

2. Exercise myocardial perfusion imaging or exercise echocardiography in patients with prior revascularization (either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). (Level of Evidence: B)

3. Adenosine or dipyridamole myocardial perfusion imaging in patients with an intermediate pretest probability of CAD and 1 of the following baseline ECG abnormalities:

a. Electronically paced ventricular rhythm. (Level of Evidence: C)
b. Left bundle-branch block. (Level of Evidence: B)

Class IIb

1. Exercise myocardial perfusion imaging and exercise echocardiography in patients with a low or high probability of CAD who have 1 of the following baseline ECG abnormalities:

a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: B)
b. More than 1 mm of ST depression. (Level of Evidence: B)

2. Adenosine or dipyridamole myocardial perfusion imaging in patients with a low or high probability of CAD and 1 of the following baseline ECG abnormalities:

a. Electronically paced ventricular rhythm. (Level of Evidence: C)
b. Left bundle-branch block. (Level of Evidence: B)

3. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate probability of CAD who have 1 of the following:

a. Digoxin use with less than 1 mm ST depression on their baseline ECG. (Level of Evidence: B)
b. LV hypertrophy with less than 1 mm ST depression on their baseline ECG. (Level of Evidence: B)

4. Exercise myocardial perfusion imaging, exercise echocardiography, adenosine or dipyridamole myocardial perfusion imaging, or dobutamine echocardiography as the initial stress test in a patient with a normal rest ECG who is not taking digoxin. (Level of Evidence: B)

5. Exercise or dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C)

”

Vote on and Suggest Revisions to the Current Guidelines

Sources

  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [2]
  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [3]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [4]

References

  1. ↑ 1.0 1.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. [1] PMID: 10351980
  2. ↑ Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). [url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [2] "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology"] Check |url= value (help). Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.
  3. ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58.[3] PMID: 12515758
  4. ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[4] PMID: 17998462


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