Persantin Thallium scan The most common nuclear cardiac imaging technique used with stress testing is myocardial

al perfusion imaging. It involves injection of a radionuclide tracer such as 201Tl (radioisotope of thallium) or a 99mTc-based (radioisotope of technetium) organic agent such as sestamibi or tetrofosmin at the time of peak coronary hyperemia induced by exercise, pharmacologically induced vasodilation (with intravenous dipyridamole i.e. active ingredient of persantin, or adenosine), or adrenergic stimulation (such as with dobutamine) The common feature of the different radionuclide perfusion agents is that they are taken up by myocardium in proportion to coronary blood flow and can be imaged with a nuclear imaging camera. (usually with single photon emission computed tomography: SPECT and positron emission tomography: PET.) Areas of reduced uptake seen on cardiac imaging correspond to hypoperfused or ischemic myocardium. Stress images are then compared with resting or delayed images to distinguish hypoperfused viable versus nonviable or infarcted myocardium. This test can also estimate left ventricular systolic size and function A major advantage of radionuclide cardiac imaging is the ability to obtain this information using nonexercise stress Fixed perfusion defects (implies old MI) do not have significant predictive value for perioperative cardiac events. Fixed thallium instead defects predict long-term cardiac events. Reversible defects (coronary insufficiency) in fewer than 20% of myocardial segments were associated with a small, non-significant increased risk of perioperative death or MI. Reversible defects that involved more than 20% of myocardial segments were associated with a significantly higher risk of perioperative cardiac death or MI that increased progressively as the extent of reversible defects increased. This test has a low positive predictive value of reversible defects for perioperative death or MI ranged from 2% to 20%. Because of the overall low positive predictive value of stress nuclear imaging, it is best used selectively in patients with a high clinical risk of perioperative cardiac events. (positive predictive value of perfusion imaging was correlated with the pretest cardiac risk of the patients) Stress nuclear myocardial perfusion imaging has a high sensitivity for

detecting patients at risk for perioperative cardiac events. In general, Stress nuclear myocardial perfusion imaging using SPECT and stress echocardiography have similar diagnostic accuracies, but stress SPECT may be slightly more sensitive though less specific than stress echocardiography. Stress nuclear myocardial perfusion imaging has a high negative predictive value of a normal approximately 99% for MI or cardiac death. Situations where this test is appropriate o Nonexercise stress test is necessary o echocardiographic image quality is likely to be poor (obesity) o If the patients have existing significant resting wall motion abnormalities o Contraindication to dobutamine stress echo: e.g. serious arrhythmias, severe hypertension, or hypotension o No contraindication to vasodilator (dipyridamole, adenosin): e.g. significant bronchospasm, critical carotid occlusive disease, theophylline

Reference: American College of Cardiology/American Heart Association Clinical Competence Statement on Stress Testing ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery Uptodate: Selecting the optimal cardiac stress test STOELTING'S ANESTHESIA AND CO-EXISTING DISEASE