Myocardial Perfusion Imaging

SPECT Basics
Coronary Artery Disease
Coronary Artery Disease
 Cardiovascular disease is the leading cause of
death in the world
Coronary Artery Disease
 Cardiovascular disease is the leading cause of
death in the world
 CAD is a condition in which the heart does not
receive enough blood
Coronary Artery Disease
 Cardiovascular disease is the leading cause of
death in the world
 CAD is a condition in which the heart does not
receive enough blood
 Caused by accumulation of plaques in the
coronary arteries
 Causes stenosis of the lumen of the vessels
 Decreases ability of the walls of the affected
vessels to contract which inhibits cardiac function
 Occlusion of the vessels can also be caused by
thrombus or embolus in a coronary artery or an
artery spasm
Risk Factors CAD
Risk Factors CAD
 High cholesterol
Risk Factors CAD
 High cholesterol
 High blood pressure
Risk Factors CAD
 High cholesterol
 High blood pressure
 Cigarette smoking
Risk Factors CAD
 High cholesterol
 High blood pressure
 Cigarette smoking
 Obesity
Risk Factors CAD
 High cholesterol
 High blood pressure
 Cigarette smoking
 Obesity
 Diabetes
Risk Factors CAD
 High cholesterol
 High blood pressure
 Cigarette smoking
 Obesity
 Diabetes
 Sedentary lifestyle
Risk Factors CAD
 High cholesterol
 High blood pressure
 Cigarette smoking
 Obesity
 Diabetes
 Sedentary lifestyle
 Family history of CAD
Risk Factors CAD
 High cholesterol
 High blood pressure
 Cigarette smoking
 Obesity
 Diabetes
 Sedentary lifestyle
 Family history of CAD
 Gender (more prevalent in males)
Symptoms of CAD
Symptoms of CAD
 Angina pectoris
 Transient pain or discomfort resulting from a temporary lack
of oxygen and nutrients to the heart muscle
 Myocardial Infarction
 A portion of the heart muscle dies resulting from inadequate
blood flow
 Changes the electrical activity of the heart
 Decreases contractility of heart in fibrous area
 Difficulty breathing
 Weakness
 Dizziness
 Perspiration
 CAD progresses over time and a person may be
asymptomatic in the early stages of the disease
Manifestations of CAD
 Before reaching > 70-80% vessel occlusion CAD may
have little or no effect on resting heart function
 When demands of the heart muscle are increased
diseased vessels cannot produce adequate blood
flow
 Coronary reserve: the ability to increase coronary
blood flow when needed
 Decreases in CAD due to increased metabolic demands of
the diseased vessels
 Patients with severe CAD will usually have
homogeneous resting regional myocardial blood flow
 Diminished blood flow at stress because of the
inability to increase blood flow when needed
Manifestations of CAD
 Before reaching > 70-80% vessel occlusion CAD may
have little or no effect on resting heart function
 When demands of the heart muscle are increased
diseased vessels cannot produce adequate blood
flow
 Coronary reserve: the ability to increase coronary
blood flow when needed
 Decreases in CAD due to increased metabolic demands of
the diseased vessels
 Patients with severe CAD will usually have
homogeneous resting regional myocardial blood flow
 Diminished blood flow at stress because of the
inability to increase blood flow when needed
Principal behind MPS
Indications of MPI
Indications of MPI
 Detection of CAD
Indications of MPI
 Detection of CAD
 Assessing functional significance of coronary
stenosis
Indications of MPI
 Detection of CAD
 Assessing functional significance of coronary
stenosis
 Evaluating prognosis and risk stratification
Indications of MPI
 Detection of CAD
 Assessing functional significance of coronary
stenosis
 Evaluating prognosis and risk stratification
 Assessing medical therapy of CAD
Indications of MPI
 Detection of CAD
 Assessing functional significance of coronary
stenosis
 Evaluating prognosis and risk stratification
 Assessing medical therapy of CAD
 Assessing cardiac viability
Contra-indications of MPI
 No stress in patients with contraindications to
exercise
Contra-indications of MPI
 No stress in patients with contraindications to
exercise
 No dipyridamole in patients with asthma
Protocols
 One-day
 Thallium 3-5mCi
 Stress Sestamibi or Tetrofosmin 10-15mCi/Rest
Sestamibi or Tetrofosmin 30-45mCi
 Two-day
 Stress Day 1
 10 - 20mCi Sestamibi or Tetrofosmin
 Rest Day 2 (if needed)
 10 - 20mCi Sestamibi or Tetrofosmin
Cardiac stress methods
 Physical stress
 treadmill
 bicycle ergometer
 Pharmacological stress
 Dipyridamole
 Adenosine
 Dobutamine
Reconstruction and Review Basics:
Slice Display

Planes of the heart that are

reconstructed in MPI are:
Horizontal Long Axis (HLA)
Short Axis (SA)
Vertical Long Axis (VLA)

Reconstructed data is viewed

at rest and stress, and the
corresponding planes and
slices are compared.

Intensity/color changes
between the two can represent
ischemic changes.

Count deficient areas that are

shared between the two can
represent fixed defects.
Reconstruction and Review Basics:
Slice Display
Why three different planes?
 To visualise all the walls of the heart
 To confirm a defect in myocardial perfusion,
i.e. for a it to be labelled as a perfusion defect,
it should be seen in at least 2 views and 2
axis.
What patterns may be seen?
1. Normal stress images
2. Perfusion defect in stress images, that shows
improvement in perfusion in the rest images
3. Perfusion defect in stress images, that stays
the same in rest images.
What patterns may be seen?
1. Normal stress test
 Normal scan
2. Perfusion defect in stress images, that shows
improvement in perfusion in the rest images
 Inducible ischaemia
3. Perfusion defect in stress images, that stays
the same in rest images.
 Fixed ischaemia
What do these patterns mean?
 Inducible ischaemia:
 Stable angina
 Unstable angina

 Fixed ischaemia:
 Myocardial infarction
 Myocardial stunning
 Myocardial hibernation
SA

VLA

HLA
Possible false negative?
Possible false negative?
 Balanced triple vessel disease