CHAPTER 10

CARDIOVASCULAR
SYSTEM
CARDIOVASCULAR SYSTEM
 Three radionuclide techniques have
gained wide clinical acceptance:
1. Measurements of cardiac function
2. Evaluation of regional myocardial
perfusion.
3. Detection of acute myocardial
infarction.
CARDIOVASCULAR SYSTEM
 The first two of these techniques,
 the measurement of cardiac function and

 the evaluation of regional myocardial

perfusion,
can be performed with the patient

at rest and / or

during exercise.
CARDIOVASCULAR SYSTEM
 This ability to study a patient at both rest
and exercise is very important as a
determination of the
‘reserve’ capacity
of either cardiac function
or myocardial perfusion
can be obtained in
this manner.
Indications include:
1. Evaluate cardiac function in patients with
shortness of breath both at rest and exercise.
2. Define changes in function due to therapy.
3. Determine if chest pain is due to coronary
artery disease.
4. Detect or measure the extent of acute
myocardial necrosis ( patients with
suspected recent heart attack ).
Myocardial Perfusion
Imaging
 Myocardial Perfusion Imaging
 It is well established that myocardial perfusion may
be normal at rest in the presence of significant
coronary obstruction.
 At rest, blood flow to myocardial regions perfused by
stenotic could be similar to that perfusing regions
supplied by totally patent vessels.
 Since radionuclide distribution parallels blood flow,
we would expect homogenous radioactivity
throughout the cardiac image at rest in patients
with normal, as well as in patients with stenotic
coronary vessel.
 EXERCISE
 PHARMACOLOGIC STRESS
two types of pharmacologic stress
 vasodilator stress agent
 to create coronary hyperemia
 dipyridamale,adenosine
 ino/chronotropic adrenergic agents
 to increase myocardial oxygen demand
 dobutamin, arbutamine
1 RADIOPHARMACEUTICALS

1.1 201Tl
(Thallium)

1.2 99mTc-MIBI
99m
Tc-Sestamibi
(2-methoxyisobutylnitrate)
1 RADIOPHARMACEUTICALS
1.1 Tl
201

 Redistribution
 In general, thallium clears more slowly from

regions supplied by stenotic vessels than from

normal myocardial regions, may even
accumulate thallium.
 This occurs because as thallium is cleared more
rapidly from well perfused regions the intravascular
concentration will increase resulting in a gradient
from the vascular space to the low concentration
(ischemic) regions (washout from normal areas
and increased uptake in viable ischemic zones).
 1 RADIOPHARMACEUTICALS

 Technique:
 Exercise---injection
 5-15min
 first imaging (stress)
 3-4h
 second imaging (redistribution)
1 RADIOPHARMACEUTICALS

1.2 99m
Tc-MIBI
 MIBI,can be used to acquire high-quality
myocardial images after 60 ~ 90 minutes of
injection.
 As the 99mTc-MIBI do not significantly
redistribute it was initially thought that a
second day injection at rest would be
necessary.
1 RADIOPHARMACEUTICALS

 Technique:
 First day - Exercise---injection
 60-90min first imaging (stress)
 next day - At rest -----injection

60-90min second imaging (rest similar to
201
Tl- redistribution)
2 Image acquisition

– Horizontal long axis slices horseshoe

– Vertical long axis slices horseshoe
– Short axis slices doughnut
– Polar bull’s eye plot plate or target
3 Image Analysis
 The normal perfusion scintigram reveals
radioactivity in all element of the viable
myocardium in proportion to perfusion.
 The greatest muscle mass will have the

greatest relative perfusion and the most

intense radioactivity.
 For this reason in the normal study the left
ventricular myocardial wall is best seen.
3 Image Analysis
 All patient with an abnormality on the stress scintigram must
be imaged at rest.
 Defect in the rest image generally indicate prior

infarction and significant coronary lesions.

 Abnormalities on the stress scintigram which are no

longer present at rest are indicative of reversible

stress-induced ischaemia.
 Comparison of rest and stress scintigrams allows
identification and differentiation of reversible ischaemia
from irreversible infarction.
3 Image Analysis
Stress Rest or Interpretation
redistribution
Nomal Not done No evidence of
CAD
Abnormal Nomal Ischaemia

Abnormal Abnormal but Ischaemia and

improved infarction
Abnormal Abnormal / no Infarction
change
5 Clinical Application
1. Detection of coronary artery disease
2. Evaluation of the extent and severity of
coronary stenosis
3. In order to assess prognosis
4. Assess myocardial viability
5. Assess outcome and efficacy of
therapy
6. Evaluation of patients who have an
uninterpretable ECG stress test
 Common indications
1. Known or suspected coronary artery
disease(CAD)
a. Diagnosis of coronary artery disease
 presence
 location (coronary territory)
 extent(number of vascular territories involved)
b. Assessment of the degree of coronary stenosis and
impact on regional perfusion
c. Myocardial viability assessment
 ischemia vs scar
 predict improvement in function following
revascularization
d. Determine prognosis (risk stratification based
on extent of myocardium in jeopardy, cavitary
dilatation and lung uptake)
e. Differentiate between coronary and non-
coronary etiologies in patients with acute
chest pain syndromes seen in the emergency
room
2. Follow-up of patients with known coronary
artery disease
Evaluate the immediate and long term
effects of:
a. Revascularization procedures (such as coronary
artery bypass grafting,angioplasty,etc.)in patients
with recurrent symptoms
b. Medical or drug therapy
c. Dietary and lifestyle modifications
3. Known or suspected congestive
heart failure
Differentiate ischemic from
idiopathic cardiomyopathy
Homework
 1. How many radionuclide techniques have gained
widely clinical acceptance in cardiac studies? Which
techniques can be performed with the patient at rest
and/or during exercise? Why?
 2.  What is the difference between 201 Tl and 99m Tc-MIBI
in myocardial perfusion imaging?
 3. The clinical application of myocardial perfusion
imaging. What are the characteristics of reversible
ischemic and irreversible infarction on myocardial
perfusion imaging?