procedure guidelines for radionuclide myocardial perfusion imaging - interactive display

1 Background myocardial perfusion imaging uses intravenous radioactive drugs to make myocardial perfusion when the perfusion system is stimulated and static.
Get the image using a gamma camera.
Due to the 3D nature of the image and the superior contrast resolution, tomography is superior to plane imaging.
The comparison of the myocardial distribution of radioactive drugs after stress and rest provides information about myocardial viability, induced perfusion abnormalities, and overall and regional myocardial function when using ECG-gated imaging.
Myocardial perfusion imaging of radionuclides
Invasive imaging techniques with diagnostic and prognostic efficacy in studies of coronary artery disease.
This is the only widely available test for direct evaluation of myocardial perfusion, but there are differences in the way this test is conducted in different centers.
Therefore, coordinating practice, at least at the national level, is essential and clinical governance now requires practice to be as evidence-based as possible.
1 This is best achieved through the analysis of evidence by experts. For this reason, the British nuclear Heart Disease Society (BNCS)
And the British Heart Society (BCS)
British Association of Nuclear Medicine (BNMS)
, A program guide for tomography myocardial perfusion imaging was developed.
The guide is designed to help doctors and other healthcare professionals recommend, perform, interpret and report a single photon emission computed tomography (SPECT)
Myocardial perfusion.
In particular cases, they do not include the advantages or disadvantages of the technology;
Nor did they address their cost-effectiveness in clinical diagnosis and management or their potential impact on clinical outcomes. oas_tag. loadAd("Middle1");
The guideline development methodology writing group consists of clinicians and scientists from different specialties, but all have sub-expertise in nuclear cardiology.
The advisory group consists of designated delegates from the National Development Centre, the National Development Centre and the National Development Centre Steering Committee.
Do everything possible to avoid non-conflict of interest
The clinical relationships and final documents were approved by the three associations.
A systematic search was conducted for Pub Med/medline 2 from January 1980 to June 2002.
Cross-referenced tomography imaging with the following terms to find relevant articles: Coronary artery disease, exercise and drug pressure, cardiac perfusion radioactive drugs, attenuation correction, artifacts, ECG gating.
The search is limited to English reports.
In addition, the previously published guidelines were reviewed (
Guide to ACC/ACP sports testing, 3, 4 ACC/AHA/ACP-
ASIM guidelines for management of patients with chronic stable coronary heart disease, 5 guidelines for nuclear cardiology procedures of the American Society of Nuclear Cardiology, 6 and guidelines for nuclear medicine procedures of the myocardial perfusion imaging Society 2. 07).
The search generated 350 references that were considered to be the most representative.
Each guide developer summarizes the relevant data and coordinates the differences in a consensus manner.
Therefore, all proposals are based on evidence from clinical research, previously published guidelines, or expert consensus from the writing and advisory groups.
The indications for radionuclides myocardial perfusion imaging are as follows.
Assess the presence and extent of coronary obstruction in patients with suspected coronary artery disease to help manage patients with known coronary artery disease: identify the possibility of future coronary events, E. G, after myocardial infarction or with the proposed non-Heart surgery
8-10 to guide the strategy of myocardial vascular reconstruction by determining the significance of blood flow dynamics in coronary artery damage.
11 assess the adequacy of puncture and surgical vascular reconstruction.
To evaluate myocardial survival and hibernation, especially the planned myocardial vascular reconstruction.
13 Special indications are: to evaluate the significance of the flow dynamics of known or suspected abnormal coronary arteries and muscle bridges.
14, 15 to evaluate the significance of blood flow dynamics in the coronary artery aneurysm of Kawasaki disease.
16,174 emphasis on Myocardial Perfusion System 4.
1 Dynamic practice 4. 1.
1 indicates that dynamic exercise is the stress technique chosen when assessing patients with suspected or known coronary artery disease, provided that the patient is able to exercise under an acceptable workload (
For example, the maximum heart rate predicted is at least 85%).
In particular, dynamic movement is an ideal form of stress for patients who suspect or know coronary artery abnormalities, muscle bridges, or vascular diseases. 4. 1.
2 patients should be considered to prepare drugs that may interfere with physiological motor response.
In general, for diagnostic studies, beta-adrenaline receptor inhibitors and rate-limited calcium channel inhibitors should stop five half-lives before testing, unless medically disabled.
Patients should also avoid foods, drinks and medications that contain caffeine at least 12 hours before the test.
This policy allows the use of blood vessel expansion agents (
Pan shengding, AMP)
In the case of termination of the exercise and under the pressure of the drug (see section 4. 2 below).
Patients should be instructed to exercise in appropriate clothes.
Fasting is not a must.
While many centers usually perform rapid examinations of patients before imaging, the advantages of this policy have not yet been confirmed. 4. 1.
3 Protocol testing must be carried out by properly trained healthcare professionals.
The National Bureau of Statistics is in the process of developing guidelines for appropriate training, but in the absence of these guidelines, there must be local instructions for appropriate training and experience.
If the test is not conducted by a doctor, then a doctor with experience in cardiovascular stress should be able to urgently seek assistance based on the circumstances defined in the local or national guidelines.
Health care professionals who oversee stress testing should be the latest in immediate life support (ILS);
Should be able to reach people with advanced life support training quickly (ALS)
Appropriate assistance and urgent support should be provided.
A medical history should be included in the preliminary assessment (
Including symptoms, coronary risk factors, medication, and previous diagnostic and treatment procedures)
If any, review the referral letter and other medical records.
Physical examination may also be required, especially if there is a suspicion of a taboo of dynamic movement, such as a obstruction of the left heart outflow channel.
According to the current legislation, the reasons and authorization for conducting the test should be confirmed before the test is started.
Dynamic exercise can be done using a treadmill or a bicycle force meter.
Most treadmill programs for exercise testing include the initial stages of warm-up, progressive uninterrupted exercise that increases the workload at each level until the end point is reached, and the recovery period.
The preferred approach is the Bruce protocol.
The bike force meter protocol typically involves an initial low workload of 25 watts, then an increase of 25 watts every two minutes until the end point is reached.
3 no matter which exercise plan is used, the intravenous line should be fixed and rinsed with 5-10 ml of 0.
Before starting the test, 9% of the salt water is injected to ensure smooth flow.
Variables of blood flow dynamics (
Heart rate and blood pressure)
ECG should be monitored during rest and throughout the testing process and recorded at each stage.
Monitoring should last for five minutes after exercise or when the change is stable, the blood flow dynamics variables and the ECG approach the baseline.
12 ECG monitoring is required to detect changes in ST and T waves and to diagnose heart rate abnormalities.
Attention should be paid to the length of exercise time, symptoms, causes of cessation and changes in dynamic ECG. 4. 1.
4 end point and radiation drug injection exercise should be limited in symptoms, with patients reaching at least 85% of the maximum predicted heart rate after age and gender adjustment.
Radioactive drugs should be injected near the peak of exercise.
Patients should continue to exercise for one minute if feasible
201 injection, or at tech-
Injection of 99 m Perfusion Tracer.
If there is: the ST segment is raised more than 0, the exercise test should be stopped.
1 mV of the wires without Q waves;
Despite the increased workload, the systolic blood pressure decreased by more than 20mm over the baseline, or by more than 20% over the previous stage, if this is considered to be related to myocardial ischemia;
Hypertension response (
Blood pressure 120mm Hg);
Severe arrhythmia (
Such as atrial fibrillation, room speed, frequent occurrence, early symptomatic room, early multi-focal room, atrial fibrillation, room speed, secondary or three-degree obstruction of the atrial tract, and delayed symptomatic cardia); severe angina;
Signs of low perfusion around, such as cyan or pale;
Symptoms of the central nervous system, such as ataxia, dizziness, or near fainting.
A horizontal or lower inclined ST depression lower than baseline rw0.
80 MS after 2 mV J is not necessarily a sign of termination of exercise, unless it is progressive or related to symptoms. 4.
Drug pressure 4. 2.
1 indicator drug pressure is a good alternative to dynamic exercise, provided that exercise tolerance, symptoms and ECG changes are not required during dynamic exercise (table 1).
It has the advantages of fast speed, reliability and good reproduction, but the disadvantage is that it is impossible to monitor the adequacy of stress, and it is not equal to the physiological stress experienced by patients in daily life.
For patients with 20, 21, and left bundle branch nerve block who are unable to exercise adequately, the drug pressure of the vascular expansion agent is the preferred procedure (LBBB)
Rhythm.
View this table: View the inline View pop-up table 1 drug pressure Protocol 4. 2.
2 patients are prepared to take at least 12 hours before the pressure test of the shuvascular agent, preferably 24 hours. the shuvascular agent emphasized by the shuvascular agent adp or double dipyridamole dammo must be rid of the food containing caffeine,
24, 25 Aminophylline and cocoa base must be stopped 24 hours prior to the trial.
26 patients with double dipyridamole Damo should stop taking the drug at least 24 hours prior to vascular expansion stress.
This process should be explained in detail, outlining possible adverse effects and complications.
The Dobutamine stress test shall stop the β-adrenaline receptor inhibitor for the first five half lives or at least 24 hours, unless disabled.
This process should be explained in detail, outlining possible adverse effects and complications. 4. 2.
3 agreement for dynamic exercise, the pressure must be borne by qualified health care professionals (See paragraph 4. 1. 3).
A preliminary assessment of the patient's medical history, the appropriate examination, and the reasons and authorization for conducting the test must be made.
When dosing, intravenous injection lines and tee joints are required to allow follow-up injections without interrupting dosing.
However, tracer injection should be given within 10 to 20 seconds to avoid a sudden injection of adp.
Use infusion or syringe pump to infusion amp for 6 minutes at 140 μg/kg/min.
When tolerated, this may be combined with submaximal dynamic movement to reduce the frequency and severity of adverse reactions associated with the infusion of vascular dilators.
28 if this is the case, the bike force meter is better than the treadmill, because intravenous injections are easy to manage when the patient is relatively stable.
During infusion, heart rate, blood pressure and ECG should be measured and recorded at baseline and every two minutes.
The radioactive drug is injected 3 to 4 minutes after infusion, and earlier if symptoms or other complications are required.
Tracking injections as early as two minutes after the start of the infusion may be effective.
Symptoms during the test should be recorded.
The double dipyridamole dammo was injected at a speed of 140 μg/kg/min for 4 minutes.
Infusion can be done manually with care, and in the case of tolerance, it can be combined with submaximal dynamic movement.
During infusion, heart rate, blood pressure and ECG should be measured and recorded at baseline and every two minutes.
Radioactive drugs should be injected 4 minutes after the infusion is completed.
Symptoms during the test should be recorded.
Adverse reactions caused by double dipyridamole Damo are similar to adp, although they are usually prolonged.
Intravenous injection of aminophylline (75–250 mg)
Although its half-life is shorter than that of double dipyridamole Damo, these effects may need to be reversed (tables 2 and 3).
30-34 View this table: View inline View pop-up table 2 Percentage of side effects reported during drug stress31-33View this table: view inline View popupTable 3 adverse events summary of patients receiving imaging30-34Dobutamine pressure from myocardial perfusion when dynamic exercise is not feasible and there is a taboo with pressure from a blood vessel expansion agent, pressure is usually used
It is in an incremental dose of 5, 10, 15, 20, 30, using infusion or syringe pump for intravenous infusion within three to five minutes, 40 μg/kg/min.
At the end of each stage, heart rate and blood pressure should be recorded and ECG should be monitored continuously.
Up to 75% of patients may have side effects during infusion (tables 2 and 3).
When 85% of the maximum predicted heart rate after age and gender adjustment is reached, or at 40 μg/kg/min, radioactive drugs should be injected, although stress may be at lower heart rate
Dobutamine infusion should continue infusion for 1 minute after tl-injection
201 or 1 to 2 minutes after injection of tech-
Tracers marked at 99 m and then stopped.
Although if 85% of the maximum predicted heart rate is not reached, heparin is given during the dobutamine ultrasound heartbeat, this may not be necessary for perfusion imaging because dobutamine
For the same reason as the exercise test, 36, 37 Dobutamine infusion should be stopped (See paragraph 4. 1. 4). 4.
3 precautions during all stress procedures a state-of-the-art healthcare professional is required to be present.
Personnel trained in ALS should be provided promptly.
Emergency equipment, medicines and auxiliary personnel should also be provided. 4.
4 taboo. 4.
1 Absolute taboo of dynamic exercise-ST-
Acute coronary syndrome.
Once stabilized, depending on the risk of clinical evaluation, it is possible to consider taking exercise pressure within 24 to 72 hours of chest pain.
38, 39 ST segment elevation myocardial infarction within the first four days.
40 major left coronary artery stenosis that may be clinically significant.
Symptomatic left heart failure.
Recently, there was a life-threatening arrhythmias.
(3) severe dynamic or fixed obstruction of the left heart outflow channel (
Aortic stenosis and obstructed heart disease).
(3) severe systemic hypertension (
Systolic blood pressure> 220mm Hg and/or systolic blood pressure> 120mm Hg).
3 Recent pulmonary embolism or myocardial infarction.
Thrombosis or deep venous thrombosis.
Heart inflammation, heart muscle pain or Zhou Yan. 34. 4.
2 Relative taboo of dynamic movement bbb, double bundle block and cardiac rhythm, because dynamic movement can cause abnormal perfusion of the diaphragm and adjacent walls without blocking coronary artery disease.
22. 23. dynamic exercise cannot or lacks motivation.
Exercise ECG with insufficient exercise recently.
These are not strict taboos of dynamic motion, but they can compromise the accuracy of the test. 4. 4.
Absolute taboo of vascular distants recent acute coronary syndrome.
Once stabilized, depending on the risk of clinical evaluation, pressure can be taken into account with a vascular drug within 24 to 72 hours after chest pain.
Severe airway spasm is suspected or known.
6 in the absence of a functional pacemaker, the second and third degrees of Lane obstruction.
6 suffer from sinus syndrome without a functional pacemaker. 6Hypotension (
Systolic blood pressure 50% of maximum myocardial intake)
, There are 62 significant tracer absorption outside the heart, or there are radioactive drugs with external infiltration in the venous puncture site;
The pattern of myocardial uptake was evaluated, although this can be seen more clearly in the tomography. 8.
3 Review of tomogram 8. 3.
1 The fault map showing the reconstruction should be viewed on the computer screen for reporting.
Reports of film or paper copies should be avoided.
Three fault faces should be shown: the vertical long axis, the horizontal long axis, and the short axis.
Continuous color marks should be used because it provides the best interobserver protocol.
63 for ECG gated and non-gated studies, if automatic edge detection is used, the edges exported by the computer should be checked to ensure that they are properly defined.
The definition of an incorrect inner and inner membrane boundary will result in the calculation of the wrong volume and ejection fraction, as well as incorrect polarity display and quantification. 558. 3.
2 The Left heart size and right heart uptake and size assessment of the fault image should start with a qualitative assessment of the left heart cavity size in both sets of images.
The more severe expansion in the pressure image than in the stationary state indicates the expansion induced by ischemia.
62 This is not very common in tech
99 m tracker due to delayed imaging.
It should be noted that the area of absorption reduction in the stress image does not simulate expansion.
Attention should also be paid to Tracer absorption in the right brain chamber.
Significant uptake of right heart tracers (
> 50% of maximum left heart intake)
Indicates that the right hypertrophy fat and the right ventricle may also expand. 648. 3.
3 in all regions of the left heart muscle, the localization, range and severity of perfusion defects should be visually evaluated.
A wide range of left ventricular myocardial models can be used for segmented analysis, with 17 models recommended by several American associations.
65 tracer uptake can be classified as normal semi-quantitatively (
Maximum absorption 100-70%)
Slightly reduced (
Maximum absorption 69-50%
Moderate reduction (
Maximum absorption of 49-30%)
Serious reduction (
Maximum absorption 29-10%), and absent (
Maximum absorption 9-0%).
These numbers are similar and should be considered for normal changes and artifacts.
Therefore, if there is a attenuation artifact, it can be judged that the lower wall has normal absorption at a much lower value. 668. 3.
4 Review of ECG gated tomography if there is a beat length histogram, the time-volume curve should be checked to ensure that the gating is appropriate.
A film examination of the gated tomogram may also give clues of insufficient gating, such as improper positioning of the cardiac gap or a reduction in counts in certain frames.
The computer-derived endometrium and the edge of the endometrium should be checked to ensure that they are properly selected.
Wall motion is best evaluated at a linear gray scale without a computer-derived edge, which can be divided into normal, low-powered, unpowered, or unpowered (paradoxical).
Computer-generated profiles may be helpful, but they should not be used as the only determinant of motion.
In a continuous color scale without a computer-derived edge, wall thickening is the best evaluation method and is associated with an increase in counts between cardiac expansion and contraction.
Computer-generated profiles may be helpful, but they should not be used as the only determinant of thickening.
Thickening can be divided into normal, reduced or non-existent.
67 although the values obtained should be examined against the initial qualitative assessment, left Xinshu end volume, end-of-contraction volume, stroke volume and ejection fraction can be automatically calculated.
Be careful when reporting obvious false values of these variables.
For example, the volume is usually too low and the shot score is too high in the small chamber. 558.
Formal quantitative analysis may not be required for routine clinical reporting.
However, it may be helpful to supplement semi-quantitative visual analysis with quantitative analysis shown by polarity, especially to measure the degree and depth of anomalies.
68 compare the polar map of the patient with the normal database, which should be gender and radionuclides specific, or perhaps institutional specific.
The alternative to the 55-pole display is the display of the weekly count profile, but this is not very common.
Any form of quantification should be validated in published studies, and those using the technology should fully describe and understand the methods used.
Quantitative results must not be reported separately or images of the results obtained without expert review. 8.
5 The results of the integrated tomography found should be integrated to achieve a final explanation: Improvement in relative tracer absorption from pressure to rest (
"Induced abnormal perfusion ")
It is usually indicated that the presence of induced ischemia.
69. the improvement of a class of tracer uptake showed mild induction of ischemia, moderate induction of ischemia in two categories and severe induction of ischemia in more than two categories.
Reduction in tracer absorption from pressure to rest without change (
"Abnormal fixed perfusion ")
It is usually expressed as myocardial infarction, and the degree of reduction indicates the cross-wall range from mild partial thickness myocardial infarction to complete thickness myocardial infarction.
The distinction between tracing the intake of the object and the real abnormality of the artifact requires experience.
The feature that is conducive to the attenuation of artifacts is the visualization of the attenuation structure in the projected image, the fixed nature of the defect (
Especially if it moves normally on ECG-gated images)
, Estimated site (
For example, the lower or front wall of a woman)
Limited range, smooth edges, poor communication with the coronary area, or unexpected findings.
However, none of these features are generally reliable.
The characteristic of displaying reconstructed artifacts is a limited mild to moderate fixed defect of the vertex (
"Thin top ")
Or strong liver or gallbladder activity after crossing the lower wall in the projected image.
61A tracer absorption deterioration from stress to rest (
"Quick track flush" or "reverse redistribution ")
It is usually false, but may suggest partial thickness myocardial infarction with patent arteries. 70,718. 6 Reporting8. 6.
1 The patient details the personal details of the patient (
Name, age, gender, address)
Should be included at the beginning of the report.
The identification number and referral source of any hospital/clinic should also be included (table 5).
View this table: View the inline View pop-up table 5 report recommendation Summary 8. 6.
2 The type of study shall specify the imaging protocol, including the radioactive drugs used, imaging techniques, sequences, and date of study. 8. 6.
3 The indications for the study shall state the clinical indications for the study, including any relevant clinical history.
This provides a rationale for this study, summarizes clinical information that may be collected from many sources, and concentrates the final conclusions. 8. 6.
4 The pressure technique used by the pressure technique shall be briefly described, including any symptoms during or after the stress period, changes in blood flow dynamics, and details of changes in the ECG (if relevant ). 8. 6.
5 The appearance of the pressure, rest and gated images should be briefly described, including an indication of the overall study quality as appropriate.
The usual practice is to report defects in the stress fault map in descending order of severity, and then explain in the same order how each defect in the rest of the fault map changes.
Tracer absorption is being described at this stage.
Conclusion clinical inference such as myocardial viability and perfusion status can be retained (see below). 8. 6.
6 conclusion in order to achieve the final explanation, the results of the study should be integrated.
66. Specifically, the report should comment on the issues that exist (if any)
Induced abnormal perfusion, myocardial infarction and obvious artificial products.
If there is any abnormality, its position (
In terms of the affected part), extent (
In terms of the number of affected segments)
The severity should be explained.
If present, the other abnormalities that need to be mentioned are left ventricular expansion (
Continuous or brief)
The lung intake of Tracer was increased, and the intake of tracer in the right heart suggested that it should be enlarged (
With or without right heart expansion)
And important Non
Intake of heart and lung tracer.
If the study is normal, this should be specifically stated, bearing in mind that even myocardial perfusion during stress does not rule out non-
Coronary artery obstruction
If clinically relevant, a statement should be made regarding the possibility of future coronary events.
This is inferred from the presence, extent and depth of induced perfusion abnormalities, known left cardiac ejection scores, and other prognostic indicators such as transient expansion and lung absorption.
If no abnormal perfusion is induced, then the ejection fraction is a major determinant of the prognosis.
This statement is preferably semi-quantitative (
For example, "the possibility of future coronary events is 5-10% per year ")
Qualitative terms (
"High", "middle" and "low ")
There is no unified explanation.
If the assessment of myocardial viability/hibernation is relevant or needs to be related to the coronary anatomy, these assessments should be reviewed taking into account the normal changes in the coronary anatomy.
Finally, it should be ensured that the conclusion answers clinical questions that prompt referral where possible, and if not, suggestions for further investigation or management may be relevant.
9 factors that affect the quality of learning.
1 insufficient pressure technique reduces the sensitivity to detect coronary artery disease (table 6).
View this table: View the inline View pop-up table 6 factors affecting the quality of learning 9.
Tracking activity and inadequate delivery of radioactive drugs can reduce image quality and may reduce diagnostic accuracy of the technology.
This may occur if the patient's weight/size of the tracer is given an erroneous activity, or if the injection is not adequately rinsed or oozed.
Tracking delivery at inappropriate times (
That is, it does not coincide with the peak stress)
It may reduce the sensitivity of the technology. 9.
3 Image reconstruction and improper filtering in the process of fault reconstruction may reduce image quality, and improper use of color or grayscale windows may lead to inaccurate diagnosis.
For quantitative analysis of regional myocardial and lung activity, attention should be paid to the activity of adjacent structures not being included in the area of interest.
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