1. NUCLEAR CARDIOLOGY- BASICS
Dr. THIRUMURTHI
CHIEF-NUCLEAR MEDICINE
MADRAS MEDICAL MISSION

2. Nuclear Medicine
Specialty in which a wide range of clinical conditions are investigated using radioactive tracers administered to the patient
It is completely different process from X-Ray, CT and MRI scan (these look at the anatomy of the body)
To look at the function of the body, Nuclear Medicine uses gamma rays

3. Nuclear Medicine
Gamma rays are very similar to X-Rays, but the major difference is that the gamma rays are emitted by pharmaceuticals injected into the bloodstream rather than being produced by machines outside the body.
Gamma rays are detected by the gamma camera

4. Gamma Rays
(from Doe Medical Sciences webpage)

5. Myocardial Perfusion Imaging
Radiopharmaceuticals :
201Thallium
Technetium based agents
PET
* Ammonia

6. Technetium based agents
99m Technetium T 1/ Hrs
Pharmaceuticals : SestaMIBI,
Tetrofosmin
SestaMIBI: Methoxy Iso Butyl Isonitrile
Passive diffusion
Uptake proportional to blood flow & no redistribution
Good quality images, gating, easy availability
& Cost effective

7. Exercise stress testing
Treadmill or bicycle ergometer
Protocols vary - symptom limited
Bruce most popular
8 stages
Incline and speed increment every 3 minutes
Target % maximum age predicted HR
Achieve at least 6 METS for diagnostic accuracy
© Continuing Medical Implementation …...bridging the care gap

8. MPI Stress Procedure Treadmill Pharmacological stress
IV Dobutamine / Adenosine
DOBUTAMINE
Max.Dosage: 40 ug / kg / min + Inj.Atropine
0.6 mg IV
ADENOSINE
Dose : 140 ug / kg / min - 6 min

9. Indications Screening of IHD
Physiological significance of lesions post CAG
Post PTCA & post CABG evaluation
Risk stratification
Myocardial viability detection

10. Diagnostic Accuracy % % Sensitivity % Specificity P r e d i c t v A u
Exercise Stress ECG1 6 7 7 4 6 9
Exercise Stress Echo1 8 5 7 9 8 3
MPI1 8 9 80 8 9
1. O’Rourke RA, et al. Circulation. 2000;102: Wackers FJ, et al. Nuclear cardiology. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th ed. Philadelphia, Pa: WB Saunders; 1997.

15. PET Myocardial Imaging
PET Perfusion Imaging
PET Metabolic Imaging

16. Flow tracers
Rb-82
0-15
N-13
Tc-99m MIBI
Tl-201

17. Metabolic tracer F-18 – fluorodeoxyglucose(FDG) F-18 –BMS 747158
I-123 BMIPP

20. Stunning Hibernation Scar
Perfusion
Metabolism
Dysfunction
Condition
Reversible
Stunning
Reversible
Hibernation
Irreversible
Scar

21. 30% OF NO PERFUSION SEGMENT SHOWS FDG UPTAKE
MIBI & FDG
30% OF NO PERFUSION SEGMENT SHOWS FDG UPTAKE

22. Influence of Viability Testing on Outcomes With Revascularization20
-80%
p<0.0001 16 16
p=NS 12
Annual Cardiac Death Rate (%)
7.7 8
6.2
3.2 4
Revasc
Med Rx
Revasc
Med Rx
Viable Non-viable
(Allman, JACC 2002; 39: )

23. ACC/AHA Recommendations for the Use of Radionuclide Techniques to Assess Myocardial Viability
Indication
Test
Class
Level of Evidence
Predicting improvement in
regional and global LV function after revascularization
Stress /redistribution/reinjection 201T II B
Rest-redistribution imaging I
Perfusion plus PET FDG imaging
Resting sestamibi imaging
Late 201Tl redistribution imaging (after stress)
IIb
Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective
LOE B: Data derived from a single randomized trial, or from nonrandomized studies

24. First-Pass Radionuclide Angiography (RNA)

25. Indications Coronary artery disease (CAD) Valvular heart disease
Congenital heart disease

26. Equilibrium Gated Radionuclide Ventriculogram
MUGA

27. Purpose Examine the function of the pumping chambers of the heart
Left ventricle measurements are more accurate than the right because of the heart’s anatomy (gated first-pass study with radionuclides that do not pass the lungs maybe used for the right ventricle)

29. BPGS - Blood Pool Gated SPECT Analysis:
                                                                                      
BPGS - Blood Pool Gated SPECT Analysis
BPGS is an interactive standalone application for the automatic segmentation & quantification of gated short axis blood pool (red blood cells, RBC) SPECT.

34. Imaging
CTPA is now the recommended initial lung imaging modality for non-massive PE. [B]
Patients with a good quality negative CTPA do not require further investigation or treatment for PE. [A]
Isotope lung scanning may be considered as the initial imaging investigation providing (a) facilities are available on site, and (b) chest radiograph is normal, and (c) there is no significant symptomatic concurrent cardiopulmonary disease, and (d) standardised reporting criteria are used, and (e) a non-diagnostic result is always followed by further imaging. [B]