Nuclear Cardiology, The Basics

Contemporary Cardiology

Christopher P. Cannon, md

SERIES EDITOR

Nuclear Cardiology, The Basics: Howto Set Up and Maintain aLaboratory, edited byFrans J. Th. Wackers, MD, PhD,Wendy Bruni, BS, CNMT, andBarry L. Zaret, MD, 2008

Therapeutic Lipidology, edited byMichael H. Davidson MD, FACC, FACP,Peter P. Toth MD, PhD, FAAFP, FAHA,

FCCP, FACC, and Kevin C. Maki, PhD,2007

Current Concepts in Cardiology:Cardiac Rehabilitation, edited byWilliam E. Kraus, MD, FACC, FACSM,

and Staven J. Keteyian, PhD, 2007Management of Acute Pulmonary

Embolism, edited by Stavros V.Konstantinides, MD, 2007

Stem Cells and MyocardialRegeneration, edited by Marc S.Penn, MD, PhD, 2007

Essential Echocardiography: APractical Handbook With DVD,edited by Scott D. Solomon, MD,2006

Preventive Cardiology: Insights Into thePrevention and Treatment ofCardiovascular Disease, SecondEdition, edited by JoAnne MicaleFoody, MD, 2006

The Art and Science of CardiacPhysical Examination: With HeartSounds and Pulse Wave Forms onCD, by Narasimhan Ranganathan,MD, Vahe Sivaciyan, MD, andFranklin B. Saksena, MD, 2006

Cardiovascular Biomarkers:Pathophysiology and DiseaseManagement, edited by David A.Morrow, MD� 2006

Cardiovascular Disease in the Elderly,edited by Gary Gerstenblith,MD� 2005

Platelet Function: Assessment,Diagnosis, and Treatment, edited

by Martin Quinn, MB BCh BAO, PhD,and Desmond Fitzgerald, MD, FRCPI,

FESC, APP� 2005Diabetes and Cardiovascular Disease,

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Angiogenesis and Direct MyocardialRevascularization, edited by RogerJ. Laham, MD, and Donald S. Baim,MD� 2005

Interventional Cardiology:Percutaneous NoncoronaryIntervention, edited by Howard C.Herrmann, MD� 2005

Principles of Molecular Cardiology,edited by Marschall S. Runge, MD,and Cam Patterson, MD� 2005

Heart Disease Diagnosis and Therapy:A Practical Approach, SecondEdition, by M. Gabriel Khan, MD,

FRCP (LONDON), FRCP(C), FACP,

FACC� 2005Cardiovascular Genomics: Gene Mining

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Nuclear

Cardiology,

The Basics

How to Set Up and Maintaina Laboratory

Second Edition

by

Frans J. Th. Wackers, md, phdYale University School of Medicine, New Haven, CT

Wendy Bruni, bs, cnmt

Yale–New Haven Hospital, New Haven, CT

and

Barry L. Zaret, md

Yale University School of Medicine, New Haven, CT

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Due diligence has been taken by the publishers, editors, and authors of this book to assure theaccuracy of the information published and to describe generally accepted practices. The contributorsherein have carefully checked to ensure that the drug selections and dosages set forth in this textare accurate and in accord with the standards accepted at the time of publication. Notwithstanding,as new research, changes in government regulations, and knowledge from clinical experiencerelating to drug therapy and drug reactions constantly occurs, the reader is advised to check theproduct information provided by the manufacturer of each drug for any change in dosages or foradditional warnings and contraindications. This is of utmost importance when the recommendeddrug herein is a new or infrequently used drug. It is the responsibility of the treating physician todetermine dosages and treatment strategies for individual patients. Further it is the responsibilityof the health care provider to ascertain the Food and Drug Administration status of each drug ordevice used in their clinical practice. The publisher, editors, and authors are not responsible forerrors or omissions or for any consequences from the application of the information presentedin this book and make no warranty, express or implied, with respect to the contents in this publication.

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Preface

In the USA, the performance of nuclear cardiology studies increaseddramatically over the past 5 to 10 years. In 2001, the number of patientvisits for myocardial perfusion imaging was 7.9 million. In 2005, thenumber of patient visits increased to 9.3 million. Roughly 96% of thesestudies used ECG-gated single-photon emission computed tomography(SPECT) imaging. Roughly half (47%) of these studies were performedin nonhospital settings (1).

The growth of nuclear cardiology as an expanded outpatientlaboratory enterprise is readily apparent. In the USA, as well as inother parts of the world, this growth has been linked to the recognitionof the ability of cardiologists to perform these studies.

Certification examination in nuclear cardiology is now an estab-lished cardiology phenomenon in the USA. Certification by one ofseveral mechanisms is now generally required for hospital privilegesin reading studies and is also often required to obtain reimbursementfor study performance and interpretation.

Accreditation of laboratories is also well established. Indeed, at thetime of this writing, we have learned that one large payor, respon-sible for 70 million lives, will require laboratory accreditation forreimbursement by March 2008.

Over the years, some of the most frequent questions asked of us byour former trainees after leaving the program relate to practical issuesinvolved in the establishment of a nuclear cardiology laboratory. Inview of the growth of the field, this is certainly not surprising.

There are a number of excellent texts on general nuclear cardi-ology available (2–5). These books generally deal with the overallconcepts of the field, its scientific basis, techniques, clinical applica-tions, and clinical value. However, to our knowledge, there does notpresently exist a volume designed to provide the nuclear cardiologistwith a manual dedicated specifically to how to establish and run a wellorganized and state-of-the-art nuclear cardiology laboratory.

Consequently, the purpose of this book is to provide the outlinefor the “nuts and bolts” establishment and operation of a nuclearcardiology laboratory. In so doing, we have attempted to deal with therelevant issues that a laboratory director must address in either settingup the laboratory or maintaining its competitive edge and clinical

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vi Preface

competence over time. We primarily attempt to identify issues relatedto outpatient imaging facilities. However, where appropriate, issuesrelated to in-patients in hospital-based laboratories are also discussed.

This book is aimed at cardiology fellows, nuclear cardiology fellows,and nuclear medicine and radiology residents completing training aswell as established cardiologists, radiologists, or nuclear physicianswho want to establish a nuclear cardiology laboratory. The bookshould also be of value to nuclear cardiology technologists, laboratorymanagers, and health maintenance organizations. Attention has alsobeen paid to those factors relevant for laboratory accreditation.

The book is organized in what we feel is a logical progression. Inthis new edition, we have kept the basic format established in the firstedition. In addition to reviewing, modifying, and updating each chapterin the first edition, we have added entirely new chapters on positronemission tomography (PET) imaging, hybrid imaging, and the clinicalappropriateness of nuclear cardiology procedures.

The initial chapter addresses what is required to establish thelaboratory in terms of equipment, availability of radiopharmaceuticals,and staff qualifications. A chapter is devoted to the types of infor-mation patients should be provided with, prior to arriving in thelaboratory. Chapters are devoted to laboratory logistics and appro-priate clinical protocols for stress studies. Several chapters deal withthe technical aspects of performance of studies, such as those acqui-sition parameters relevant for high-quality studies, processing param-eters, and quantification and display options. Sections on attenuationcorrection have been expanded. Examples are given of commonlyencountered artifacts. We deal with issues relating to networking,both within one laboratory and linking several laboratories. Issuesrelating to dictation and reporting, coding and reimbursement, andquality assurance are also separately addressed. Finally, we addresskey policy issues that are relevant to high-quality clinical performanceand conclude with a chapter addressing issues relevant to laboratoryaccreditation. The new chapter on PET imaging and hybrid imagingreflects new clinical advances in the field since the first edition. It islikely that these technologies will have an increasing clinical utilizationin the immediate and near future. The new chapter on appropriatenessguidelines reflects the recent joint attempt of ACC/ASNC to establishclinical criteria for technology utilization. It is important for practionersof nuclear cardiology to perform studies only when appropriate. It isnot enough to run a highly capable technologic enterprise; it must beclinically relevant as well.

Preface vii

We are hopeful that this second edition will continue to fill animportant clinical need within the cardiology and imaging commu-nities. The book has been designed to be straightforward and to dealdirectly with the issues at hand and to build on the strengths estab-lished in the first edition. In many instances, we present several sidesof a particular issue. The final decision on which approach to take willdepend on local circumstances.

Finally, in conclusion, it is very important to acknowledge themultiple lessons we have learned from the many technologists andtrainees, both in cardiology and nuclear medicine who have passedthrough our laboratory over the past two decades. Their input, aswell as the opportunity to take part in their training, has helped usenormously in the conception and writing of this book. Some ofthe useful websites are http://www.asnc.org, http://www.cbnc.org, andhttp://www.icanl.org.

Frans J. Th. Wackers, MD, PHD

Wendy Bruni, BS, CNMT

Barry L. Zaret, MD

REFERENCES

1. IMV Medical Information Division (2006). 2005 Nuclear Medicine CensusSummary Report. Available at http://www.imvlimited.com/mid/.

2. Zaret BL, Beller GA (eds) (2005). Clinical Nuclear Cardiology, State of the Artand Future Directions, 3rd Edition. Elsevier Mosby, Philadelphia, PA.

3. Iskandrian AE, Verani MS (eds) (2003). Nuclear Cardiac Imaging, Principlesand Applications, 3rd Edition. Oxford University Press, New York, NY.

4. Gerson MC (ed.) (1997). Cardiac Nuclear Medicine, 3rd Edition. McGraw-Hill,New York, NY.

5. Sandler MP, Coleman RE, Patton JA, Wackers FJTh, Gottschalk A (eds) (2003).Diagnostic Nuclear Medicine, 4th Edition. Lippincott Williams & Wilkins,Philadelphia, PA.

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Using This Book and the Companion CD . . . . . . . . . . . . . . . . . . . . xix

1 Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Laboratory Logistics . . . . . . . . . . . . . . . . . . . . . . . . 273 Radiation Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 Patient Preparation . . . . . . . . . . . . . . . . . . . . . . . . . 455 Stress Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 536 SPECT Myocardial Perfusion Imaging:

Acquisition and Processing Protocols . . . . . . . . . . 777 Planar Myocardial Perfusion Imaging:

Acquisition and Processing Protocols . . . . . . . . . . 1018 Planar Equilibrium Radionuclide

Angiocardiography:Acquisition and Processing Protocols . . . . . . . . . . 109

9 SPECT Equilibrium RadionuclideAngiocardiography:Acquisition and Processing Protocols . . . . . . . . . . 121

10 Display and Analysis of SPECT MyocardialPerfusion Images . . . . . . . . . . . . . . . . . . . . . . . . . 129

11 Acquisition, Processing, Display, and Analysisof PET Images . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

12 Hybrid Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . 21113 Display and Analysis of Planar Myocardial

Perfusion Images . . . . . . . . . . . . . . . . . . . . . . . . . 21914 Display and Analysis of Planar Equilibrium

Radionuclide Angiocardiography . . . . . . . . . . . 22715 Display and Analysis of SPECT Equilibrium

Radionuclide Angiocardiography . . . . . . . . . . . 23316 Artifacts and Technical Problems in Cardiac

Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24317 Nuclear Cardiology Reports . . . . . . . . . . . . . . . . . 349

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x Contents

18 Remote Reading and Networking:Tele-Nuclear Cardiology . . . . . . . . . . . . . . . . . . . 361

19 Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . 36720 Miscellaneous Additional Laboratory

Protocols and Policies . . . . . . . . . . . . . . . . . . . . . 38321 Emergency Department Imaging . . . . . . . . . . . . . 39722 Laboratory Accreditation . . . . . . . . . . . . . . . . . . . . 40523 Coding and Billing . . . . . . . . . . . . . . . . . . . . . . . . . 41124 Appropriateness Criteria for Nuclear

Cardiology Procedures . . . . . . . . . . . . . . . . . . . . 419Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431

Acknowledgments

We are grateful for the invaluable work done by Vera Tsatkin,CNMT, Donna Natale, CNMT, Mary Jo Zito, CNMT, Chris Weyman,CNMT, and Ramesch Chettiar, CNMT, by providing help and expertisewith the collection and formatting of the illustrations in this book.We also acknowledge Suman Tandon, MD, Matt Al-Shaer, MD, Yi-Hwa Liu, PhD, Patricia Aaronson, Stefanie L. Margulies, CNMT,and Chris Gallagher for reviewing selected portions of the manuscriptand providing valuable input. We also thank Ernest V. Garcia, PhD,Guido Germano, PhD, and Edward Ficaro, PhD, for providing us withillustrations of their proprietary software.

xi

About the Authors

Frans J. Th. Wackers, md, phd

Frans J. Th. Wackers, md, is Professor of Diagnostic Radiology andMedicine and served as Director of the Cardiovascular Nuclear ImagingLaboratory at Yale University School of Medicine for 22 years.

Born in Echt, The Netherlands, Dr. Wackers received both hisMD and PhD degrees from the University of Amsterdam School ofMedicine in 1970. He completed training in Internal Medicine andCardiology in the former Wilhelmina Gasthuis, Amsterdam in 1977.Dr. Wackers moved to the USA in 1977, where he was on the facultyof the Section of Cardiovascular Medicine at Yale University School ofMedicine (1977–1981), the University of Vermont College of Medicine(1981–1984), and since 1984 at Yale University School of Medicine.

Dr. Wackers is a Fellow of the American College of Cardiology; aFellow of the American Heart Association, Council on Clinical Cardi-ology; a member of the Society of Nuclear Medicine; and a memberand Fellow of the American Society of Nuclear Cardiology. He is also aDiploma European Cardiologist of European Society of Cardiology. Heis on the Editorial Board of the Journal of the American College of Cardi-ology, the American Journal of Cardiology, and the Journal of NuclearCardiology. He was President of the Cardiovascular Council of TheSociety of Nuclear Medicine (1992–1993), President of the American

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xiv About the Authors

Society of Nuclear Cardiology (1994–1995), President of the Certifi-cation Council of Nuclear Cardiology (1996–1997), and President ofthe Intersocietal Commission for Accreditation of Nuclear Laboratories(1997–2005). He is the recipient of the Rescar Award of the Universityof Maastricht, The Netherlands (1988), the Herrman Blumgart Award ofthe Society of Nuclear Medicine, New England Chapter (1995), the HomiBaba Award of the Indian Nuclear Cardiological Society (1997), theEugene Drake Award of the American Heart Association, New EnglandAffiliate (1999), the Distinguished Service Award of the Society ofNuclear Cardiology (1999), the third Mario Verani Memorial Lecturerof the American Society of Nuclear Cardiology (2004), the WenckebachLecturer of the Dutch Society of Cardiology (2005), and the Mario VeraniLecturer of Methodist Hospital, Houston, Texas (2006).

Dr. Wackers is considered a pioneer in Nuclear Cardiology. He isthe founder of the American Society of Nuclear Cardiology (1993),the Certification Board of Nuclear Cardiology (1996), and the Interso-cietal Commission for Accreditation of Nuclear laboratories (1997). Hewas Co-Chair of the 6th and 7th International Conference of NuclearCardiology (2003 and 2005, repectively).

Dr. Wackers has published more than 300 articles on nuclear cardi-ology and clinical cardiology.

Dr. Wackers is presently the Principal Investigator and Chairmanof the multicenter Detection of Ischemia in Asymptomatic Diabetics(DIAD) study. The study began in September 2000, recruitment wascompleted in August 2002, and continued until September 2007.

Dr. Wackers is also the director of the Yale University Radionu-clide Core laboratory. The laboratory has been involved in numerousmulticenter clinical studies utilizing cardiac nuclear imaging since itsinception in 1984.

About the Authors xv

Wendi Bruni, bs, cnmt

Wendy Bruni is manager of the Nuclear Cardiology and NuclearMedicine laboratories of the Department of Diagnostic Radiology atYale-New Haven Hospital, New Haven, CT. She served as chieftechnologist of the Cardiovascular Nuclear Imaging Laboratory for10 years. Ms. Bruni received her BS in nuclear medicine from theRochester Institute of Technology, Rochester, NY, in 1986. Sheworked in the nuclear medicine department at the Community GeneralHospital, Syracuse, NY, from 1986 to 1992. In 1992, she moved toYale-New Haven Hospital. In 1995, she became Chief Technologistof the Yale Nuclear Cardiology Department. In 2004, she became theadministrative manager of Yale-New Haven Hospital Nuclear Cardi-ology and Nuclear Medicine laboratories.

Ms. Bruni is an active member of the American Society of NuclearCardiology, participating in the technologist, newsletter, and programcommittees. She was secretary of the New England Chapter of theSociety of Nuclear Medicine (1999) and Chair of the Nuclear Cardi-ology Council of the Society of Nuclear Medicine TechnologistSection. Ms. Bruni was selected to be on the panel of nuclear cardi-ology technologists who helped the NMTCB evaluate the NuclearCardiology Specialty Exam for technologists. She was one of the firstto obtain the specialty certification of Nuclear Cardiology (NCT) inJune 2001.

xvi About the Authors

Barry L. Zaret, md

Barry L. Zaret, MD, is Robert W. Berliner Professor of Medicine(Cardiovascular Medicine) and Professor of Diagnosis Radiology. Heserved as Chief of Cardiovascular Medicine at Yale University for 26years.

Dr. Zaret received his BS degree from Queens College, CityUniversity of New York, and MD degree from New York UniversitySchool of Medicine.

He completed training in cardiology in 1971 at The Johns HopkinsUniversity School of Medicine. He became Chief of Cardiology atYale University School of Medicine in 1978.

He is a Fellow of the American College of Cardiology; Fellowof the American Heart Association; and a Founding member of theAmerican Society of Nuclear Cardiology. He is founding Editor-in-Chief of the Journal of Nuclear Cardiology and is on the EditorialBoard of the Circulation, the Journal of the American College ofCardiology, the American Journal of Cardiology, and the Journal ofNuclear Cardiology. He was president of the Association of Professorsof Cardiology (1992–1993).

He has received numerous awards and recognitions, including theHerrman Blumgart Award of the Society of Nuclear Medicine, NewEngland Chapter (1978), the Louis Sudler Lecturer and Medalist, Rush-Presbyterian Mediacl College (1993), the Award for Contribution andLeadership in Noninvasive Cardiology, 4th International Conferenceon Noninvasive Cardiology, Cyprus (1993), the 29th Nathan J. KivenOrator award, Providence RI (1996), The Solomon A. Berson MedicalAlumni Achievement Award in Clinical Science, New York University

About the Authors xvii

School of Medicine (1998), Co-Chair of the 1st and 2nd InternationalConference of Nuclear Cardiology (1993 and 1995, respectively),Co-Director of the 2nd, 3rd, and 4th Wintergreen Conference onNuclear Cardiology (1994, 1996, 1998, respectively), First Samuel andPatsy Paine Lecturer, University of Texas (2001), 2nd Annual MarioVerani Lecture, American Society of Nuclear Cardiology (2003), theEllis Island Medal of Honor (2003), and the American Society ofNuclear Cardiology Distinguished Service Award (2006).

Dr. Zaret is considered one of the founders and present leadersof the subspecialty of Nuclear Cardiology. He has made numerouscontributions to cardiology literature on myocardial perfusion imagingand assessment of cardiac function using radionuclide imagingmethodology.

Using This Book

and the Companion CD

All illustrations and movies in this book can be found in digitalformat on the accompanying CD. The images are best viewed ona high-resolution (1280 × 1280) color (24-bit or higher true color)computer monitor. The movies are best viewed at a display of 8–10frames per second.

xix