1. Nuclear Cardiology Guidelines
Benchmark to compare local practice against

2. UK Guidelines British Nuclear Cardiology Society
British Nuclear medicine Society
British Cardiac Society
Draft - Rev
21 pages

3. USA (1) - SNM Society of Nuclear Medicine Version 2.0 1999
14 pages

4. USA (2) - ASNC American Society of Nuclear Cardiology
Two part guidelines ( )
84 close-typed pages

5. Techniques Covered BNCS SNM ASNC MPI -Planar  MPI - SPECT
MPI - Gated 
MUGA
First Pass
PET
 = Covered in detail  = Mentioned

6. MPI – SPECT: Aspects Covered
BNCS
SNM
ASNC
Clinical Indications 
Stress Techniques
Radiopharmaceuticals
Equipment QA
Acquisition 
Processing and Display
Artefacts and Pitfalls
Report Content/Style

7. Doses (MBq) BNCS SNM ASNC Thallium 80 < 150 110 Tc-99m (1-day)
<1400
(2-day)
2 * 400
2 * 1100 (max)
2 * 800
Boost for
obese pt?  
FDA max

8. Stress Methods Methods Exercise (treadmill or bike) Pharmacological
Adenosine
Dipyridamole
Dobutamine
Contraindications
Stop conditions

9. Acquisition LEHR parallel hole collimator
Circular or non-circular orbit
20% symmetric energy window
64 x 64 or 128 x 128 (optional)
Zoom can be used
Take care heart always in view (BNCS)
Pixel size
around 6mm (BNCS) 6.4±0.2 mm (ASNC)
cf Picker 4.9mm (64*64, 1.8mag)
imaging time min
Continuous or S&S with 32/64 stops

10. Processing: stages and options

11. Motion Correction
All guidelines state that patient motion should be assessed
SNM gives acceptable limits: ±1 pixel in axial direction in a 64x64 study
Repeat acquisition or optionally use software methods for minor motion

12. Filtering - ASNC Not prescriptive Discusses filter types
“Conventional”
Butterworth/Hamming/Hanning
“Restorative” / “Contrast Enhancement”
Wiener/Metz
For gated, recommend “0.55 or 0.45 Nyquist frequency cutoff” for Butterworth
Iterative reconstruction an option if available

13. Filtering - BNCS
“Filtered back projection using Butterworth and Hanning filters is the most common method of reconstruction. Cut-off frequencies of 0.5 and 0.75 respectively are normally chosen, and these should be the same for each patient and should not be altered to compensate for low-count images in order to maintain consistency of appearance.
Iterative reconstruction is preferred if attenuation correction has been performed and it can also be used without attenuation correction.”

15. Attenuation Correction (Transmission sources)
Attenuation correction methods “in rapid development”..“difficult to provide ‘cookbook’ guidelines” (ASNC)
“The effectiveness of these techniques in routine clinical practice is currently uncertain. They should currently be used only in experienced centres and preferably as part of a formal evaluation of their value” (BNCS)”

16. Reformatting & Display
SA / HLA / VLA slices
Stress and rest with frames aligned or interactive manipulation
Report from computer display (not hardcopy)
A “continuous” colour scale (BNCS)
NO guidance on combining adjacent slices

17. Normalisation of frames
Each set of tomograms should be displayed using a window maximum that corresponds to the maximum within the myocardium in each set. Displays that set the maximum of the window to the maximum of each tomogram and those that use the same maximum for stress and rest images should not be used. (BNCS)
“Preferred” ..”frame normalization” ..normalized to the brightest pixel in each frame. That method provides optimal image quality of each slice. Drawback..gradations in activity between slices in a series may be lost. (ASNC)

18. Quantification
ASNC guidelines detail semi-quantitative segmental “scoring” systems
Full quantification (QGS etc)
Mentioned briefly in ASNC and BNCS
Always as a supplement to visual analysis
May have benefits for inexperienced observers and for serial comparison of studies

19. Report Contents Patient Details Indications Stress
agent / dose / protocol / response /ECG changes
Study Quality
Findings
Ventricular dilatation, Lung Uptake
Perfusion defects (severity/extent/“reversibility”)
Conclusion
Prognosis / recommendations

20. Sources of error Submaximal stress Inadequate dose for BMI Acquisition
Poor positioning/orbit, Wrong energy window
Patient motion, Attenuation artefacts
Reconstruction and processing
Inappropriate filter / reconstruction technique
Wrong alignment
Image display
Inappropriate colour scale or windowing
Comparison of inappropriate frames/slices

21. Conclusion Lots of useful information
Not a complete “cookbook” - still lots of scope for differences that may affect final result, especially in processing and display
Local audit may have value