Dennis A. Calnon

Single photon-emission computed tomography

The current document is an update of an earlier version of single photon emission tomography (SPECT) guidelines that was developed by the American Society of Nuclear Cardiology. Although that document was only published a few years ago, there have been significant advances in camera technology, imaging protocols, and reconstruction algorithms that prompted the need for a revised document. This publication is designed to provide imaging guidelines for physicians and technologists who are qualified to practice nuclear cardiology. While the information supplied in this document has been carefully reviewed by experts in the field, the document should not be considered medical advice or a professional service. We are cognizant that SPECT technology is evolving rapidly and that these recommendations may need further revision in the near future. Hence, the imaging guidelines described in this publication should not be used in clinical studies until they have been reviewed and approved by qualified physicians and technologists from their own particular institutions. 2. INSTRUMENTATION QUALITY ASSURANCE AND PERFORMANCE

Recent advances in cardiac PET and PET/CT myocardial perfusion imaging

Cardiovascular imaging has gained an important role in the evaluation of patients with either known or suspected coronary artery disease. The choices have expanded, imaging procedures have improved. Currently, testing procedures include echocardiography, magnetic resonance imaging, cardiac CTA, cardiac catheterization, and nuclear myocardial perfusion imaging with either single photon emission computed tomography (SPECT) or positron emission tomography (PET). Each of these imaging modalities has its strengths and weaknesses. However, SPECT myocardial perfusion imaging has emerged as a reliable and widely available tool for physicians to use in the assessment of their patient for the exclusion or presence and severity of CAD. Recently, cardiac PET has emerged as an alternative to SPECT imaging. Cardiac positron emission tomography (PET) imaging has gained considerable support and use in the field of cardiovascular imaging over the past several years. For example, delivery of the most accessible PET tracer, Rubidium-82 (RB-82) has quadrupled; the use of myocardial viability studies has increased, and the value of cardiac PET perfusion imaging is now being recognized. This recent increase in activity and interest has been spearheaded by several factors, such as availability of the camera technology, advances in cardiac PET acquisition and perfusion procedures, improved display procedures and software, as well as literature supporting the diagnostic and prognostic accuracy of PET perfusion imaging. This review will highlight cardiac PET as presented in a recent symposium with regards to differences between SPECT imaging and PET, literature supporting cardiac PET for both diagnostic accuracy and risk stratification, and features of cardiac PET/CT that differentiate it from SPECT. The review includes recent literature advances.

The role of radionuclide myocardial perfusion imaging for asymptomatic individuals.

Radionuclide myocardial perfusion imaging (RMPI) has served as a clinical mainstay in the management of patients with known or suspected coronary artery disease (CAD) for more than two decades. RMPI provides information beyond the mere detection of disease, delineating the extent, severity, and location of perfusion abnormalities. These data also have important prognostic implications and assist in providing reassurance to the clinician and patient or suggest the need for additional therapies. However, the role of RMPI among asymptomatic patients is less defined than among those with active symptoms. Furthermore, in keeping with the recent emphasis on improved resource utilization, costcontainment, and reduction of radiation exposure, the American Society of Nuclear Cardiology (ASNC) has commissioned a review of evidence for the use of RMPI specifically for asymptomatic individuals in an attempt to provide guidance for clinicians. The notation of symptomatic status remains a challenge since this designation is largely given to patient exhibiting chest pain suggestive of myocardial ischemia. Other symptoms such as dyspnea or syncope are often assigned to those without symptoms (i.e., no chest pain). For these patients with atypical presentations, the symptom burden places them at an elevated risk and may require additional assessment even though they may not have chest pain. Additionally, ischemic-type abnormalities on a resting electrocardiogram (ECG) connote an increased risk of cardiac events. The most recent Appropriate Use Criteria for Cardiac Radionuclide Imaging document discriminates between asymptomatic patients and those with an ischemic equivalent, the latter including chest pain, anginal equivalents, or an abnormal ECG. The goal of this Information Statement is to define instances when the additional evaluation of asymptomatic patients may offer useful clinical information. In contrast, the elimination of the use of RMPI in patient groups where no benefit may be garnered serves as an important means to reduce radiation exposure.

American Society of Nuclear Cardiology and Society of Nuclear Medicine and Molecular Imaging Joint Position Statement on the Clinical Indications for Myocardial Perfusion PET

Expert Content Reviewers: Frank M. Bengel MD, Daniel S. Berman MD, Dennis A. Calnon MD, Paolo Camici MD, James A. Case PhD, Manuel D. Cerqueira MD, Panithaya Chareonthaitawee MD, Robert A. deKemp PhD, Dominique Delbeke MD, PhD, Marcelo F. Di Carli MD, Sharmila Dorbala MD, James W. Fletcher MD, Henry Gewirtz MD, K. Lance Gould MD, PhD, Robert Gropler MD, PhD, Justin A. Lundbye MD, Jamshid Maddahi MD, Terrence Ruddy MD, Heinz R. Schelbert MD, PhD, Thomas H. Schindler MD, Leslee J. Shaw PhD, H. William Strauss MD, and Patrick White MPH

ASNC Model Coverage Policy: Cardiac positron emission tomographic imaging

This document is intended as a model coverage policy for cardiac positron emission tomography (PET) imaging studies and delineates under which clinical situations such a study is indicated. This document examines a variety of patient clinical indications and symptoms which support the use of cardiac PET by cross-referencing the indication with the appropriate use criteria (AUC) for radionuclide studies developed by the American College of Cardiology (ACC)/American Society of Nuclear Cardiology (ASNC) in 2005 and subsequently revised in 2009. In addition, the use of cardiac PET in patients with the indications delineated in the policy is supported by references to an abundance of the literature in the provided scenarios. Finally, we have provided the International Classification of Diseases (ICD)-9 codes which correlate to each of the indications to demonstrate which codes, or ranges of codes, are appropriate for each clinical indication.

ASNC model coverage policy: single photon myocardial perfusion imaging.

This document is intended as a model coverage policy for SPECT myocardial perfusion imaging (MPI) studies and delineates under what clinical indications such a study is appropriate to administer to patients. This document examines a variety of clinical indications and symptoms that a common patient would present with and supports the use of performing such a study by crossreferencing the indication with the multi-society appropriate use criteria for radionuclide studies developed by the American College of Cardiology (ACC)/ASNC in 2005, and subsequently revised in 2009. In addition, the use of SPECT MPI in patients with the indications delineated in the policy is supported by references to an abundance of literature which supports the use of this study in the provided scenarios. Finally, we have provided the ICD-9 codes which correlate to each of the indications to demonstrate what codes, or ranges of codes, are appropriate for each clinical indication.