Chronic stable angina myocardial perfusion scintigraphy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Associate Editor(s)-In-Chief: ; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Synonyms and keywords: Myocardial perfusion imaging, MPI, myocardial perfusion scan, exercise myocardial perfusion imaging, stress thalium scan, nuclear stress test.

Overview
In patients with baseline ECG abnormalities,a myocardial perfusion test can be used to localize the region of ischemia. Thallium-201 and technetium-99m are the two radio-labeled agents that are frequently used for the assessment of myocardial perfusion. Myocardial uptake of thallium-201 chloride is directly proportional to the regional myocardial blood flow and is dependent on the presence of viable myocardium. In patients with known CAD, a normal thallium stress test without a perfusion defect is indicative of a benign process and associated with excellent prognosis. Patients with a normal thallium scan are at low risk for CAD and subsequent coronary angiography is indicated only if the patient has a high probabilty Duke treadmill score. Contraindications for thallium stress test include the presence of arrhythmia, acute myocarditis, severe aortic stenosis and acute MI within the past 2 days.

Indications

 * Myocardial perfusion scintigraphy with thallium-201 is frequently employed as a noninvasive test to evaluate abnormalities of myocardial perfusion in patients with established or suspected CAD.


 * Thallium images may be planar or tomographic (single photon emission computed tomography=SPECT). The latter are more accurate and are therefore used more frequently to assess the presence and extent of ischemic and infarcted myocardium.

Mechanism of Benefit

 * Myocardial uptake of thallium-201 chloride is proportional to regional myocardial blood flow and is dependent on the presence of viable myocardium.


 * During exercise, the magnitude of the increase in blood flow to the non-ischemic myocardial zones is greater than to the zones supplied by stenotic coronary arteries. Due to heterogeneous distribution of blood flow, the relative extraction of thallium by non-ischemic myocardium is greater than that by ischemic myocardium.
 * During exercise thallium testing, the isotope is administered intravenously during peak exercise, and stress images are obtained immediately after discontinuation of exercise. These images reveal a decreased uptake by the ischemic myocardium, creating a perfusion defect.
 * Redistribution images are obtained after 4 hours. Myocardium that was ischemic during stress but that is not ischemic at rest now extracts the isotope. Therefore, the perfusion defects during stress images are not observed in the rest images, and these reversible perfusion defects indicate the presence of viable myocardium.
 * If the perfusion defects in stress images persist in the rest images, that is, if the perfusion defects are fixed, the myocardium is usually necrotic or fibrotic.


 * A repeat injection of thallium and scanning 24 hours after stress can distinguish severely ischemic area from viable myocardium.

Sensitivity and Specificity

 * In pooled analyses from multiple studies, the sensitivity for detecting coronary artery disease (CAD) using exercise treadmill thallium myocardium scintigraphy was approximately 84%. The specificity of excluding CAD using this test was approximately 88%. The sensitivity approaches 90% with a quantitative computer-assisted analysis of the images; during which, there is no loss of specificity.
 * Considerable experience is required for the performance and interpretation of exercise thallium scintigraphy to achieve a high degree of specificity and sensitivity.


 * Exercise thallium scintigraphy is less likely than exercise ECG to provide false positive test results in women.
 * Exercise thalloum scintigraphy may, however, give false positive test results in patients with:
 * Hypertrophic cardiomyopathy
 * Dilated cardiomyopathy
 * Infiltrative cardiomyopathy


 * Like the exercise ECG, thallium stress scintigraphy is less sensitive in the diagnosis of single vessel disease, particularly of circumflex coronary artery stenosis, than in multi-vessel coronary artery disease.

Technetium-99m

 * Technetium-99m, a calcium analog with a higher photon energy and a shorter half life than thallium chloride, can be linked to a variety of agents.
 * Technetium-99m-sestamibi is an isonitrile compound that, like thallium, is taken up by the myocardium proportional to blood flow but in contrast to thallium does not undergo redistribution.

Indications

 * Technetium-99m is used as a marker of myocardial perfusion.
 * Tomographic images with technetium-99m also allow images to be acquired on the first pass through the ventricle and can be used to assess the left ventricular ejection fraction.


 * As a noninvasive, less expensive and readily available test at care centers, echocardiography is usually the preferable method for this purpose.

==ACC / AHA Guidelines- Nuclear Stress Testing in patients Who Are Able to Exercise (DO NOT EDIT) == {{cquote|

Class I
1. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate pretest probability of CAD who have 1 of the following baseline ECG abnormalities:
 * a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: B)
 * b. More than 1 mm of rest ST depression. (Level of Evidence: B)

2. Exercise myocardial perfusion imaging or exercise echocardiography in patients with prior revascularization (either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). (Level of Evidence: B)

3. Adenosine or dipyridamole myocardial perfusion imaging in patients with an intermediate pretest probability of CAD and 1 of the following baseline ECG abnormalities:
 * a. Electronically paced ventricular rhythm. (Level of Evidence: C)
 * b. Left bundle-branch block. (Level of Evidence: B)

Class IIb
1. Exercise myocardial perfusion imaging and exercise echocardiography in patients with a low or high probability of CAD who have 1 of the following baseline ECG abnormalities:
 * a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: B)
 * b. More than 1 mm of ST depression. (Level of Evidence: B)

2. Adenosine or dipyridamole myocardial perfusion imaging in patients with a low or high probability of CAD and 1 of the following baseline ECG abnormalities:
 * a. Electronically paced ventricular rhythm. (Level of Evidence: C)
 * b. Left bundle-branch block. (Level of Evidence: B)

3. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate probability of CAD who have 1 of the following:
 * a. Digoxin use with less than 1 mm ST depression on their baseline ECG. (Level of Evidence: B)
 * b. LV hypertrophy with less than 1 mm ST depression on their baseline ECG. (Level of Evidence: B)

4. Exercise myocardial perfusion imaging, exercise echocardiography, adenosine or dipyridamole myocardial perfusion imaging, or dobutamine echocardiography as the initial stress test in a patient with a normal rest ECG who is not taking digoxin. (Level of Evidence: B)

5. Exercise or dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C)}}

Related Chapters

 * Stress Radionuclide Myocardial Perfusion Imaging


 * Comparison of exercise SPECT imaging and Exercise Echocardiography


 * Techniques used to Assess Myocardial Viability

Vote on and Suggest Revisions to the Current Guidelines

 * The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina


 * Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology


 * The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina


 * The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina