Cardiac Indices in Myocardial Perfusion Scan and Their Impact on the Patient's Prognosis Dr. Narjess Ayati, MD. FEBNM Nuclear Medicine Research Center Mashhad University of Medical Science

The Importance of Topic Coronary Artery Disease (CAD) is one of the most important leading causes of death all over the world. The current paradigm in disease management is of a risk-based approach. Proper risk stratification is critical for the management of patients with known or suspected CAD.

The Importance of Topic (2): MPI because of its non-invasive nature, high diagnostic accuracy and expansive functional and metabolic information, is of critical importance for prognosis assessment and risk stratification. Currently, MPI is considered the gold standard method for prognosis evaluation in CAD. Cardiologists' main expectation from nuclear physicians is to define event risk .

MPI

Quantification Visual Scoring 0 1 2 3 4

Semi-quantitative Scoring

Semi-quantification and its value Summed Stress Score (SSS) Summed Rest Score (SRS) Summed Difference Score (SDS) % of LV involvement SSS<4 , SSS≤3 (<4-6% of LV) Low risk :SSS=4-8 (9) Moderate risk: SSS=8.1-12 (13) High risk: SSS>12 (13)

Semi-quantification and its value Circulation ; 1998;535-43

Other indices assessed by MPI: QPS:

GHAEM HOSPITAL NUCLEAR MEDICINE DEPARTMENT RE: Mr. 92/1/20 GATED MYOCARDIAL PERFUSION SPECT: After IV injection of 0.568mg/kg of Dipyridamole, 20mCi of Tc-99m-MIBI was injected intravenously and scanning was performed in supine & prone positions and using gated SPECT technique. On the other day, the rest phase was performed with the same protocol. The scan showed absent tracer uptake in the apex, anteroapical, inferoapical ,and apicolateral segments with no improvement in the rest phase. The scan also showed decreased tracer uptake in the mid anterior, and mid inferior segments as well as inferolateral wall with partial improvement in the rest phase. On the gated SPECT images akinesia of apex and apical segments , and hypokinesia of the inferior and inferolateral walls were noted. Calculated stress-LVEF was 33% and rest-EF was 45%. Summed stress score was 25 and summed rest score was 18 LV cavity was dilated and RV cavity was visualized. INTERPRETATION: Myocardial infarction with no viability of apex, anteroapical, inferoapical,and apicolateral segments. Myocardial infarction with peri-infarct ischemia of the mid anterior,and mid inferior segments as well as inferolateral wall. Akinesia of apex and apical segments ,and hypokinesia of the inferior and inferolateral walls. 6) StressLVEF=33% & Rest LVEF=45% (myocardial stunning) 7) SSS= 25 SDS=7 8) LV cavity dilatation & RV visualization. (The scan pattern is in favor of LAD & LCX involvement , The patient is in high risk category)

Functional Indices: QGS: SMS STS SEF(%) REF(%) Stunning SHR RHR EDV ESV

6) StressLVEF=33% & Rest LVEF=45% (myocardial stunning) GHAEM HOSPITAL NUCLEAR MEDICINE DEPARTMENT RE: Mr. 92/1/20 GATED MYOCARDIAL PERFUSION SPECT: After IV injection of 0.568mg/kg of Dipyridamole, 20mCi of Tc-99m-MIBI was injected intravenously and scanning was performed in supine & prone positions and using gated SPECT technique. On the other day, the rest phase was performed with the same protocol. The scan showed absent tracer uptake in the apex, anteroapical, inferoapical ,and apicolateral segments with no improvement in the rest phase. The scan also showed decreased tracer uptake in the mid anterior, and mid inferior segments as well as inferolateral wall with partial improvement in the rest phase. On the gated SPECT images akinesia of apex and apical segments , and hypokinesia of the inferior and inferolateral walls were noted. Calculated stress-LVEF was 33% and rest-EF was 45%. Summed stress score was 25 and summed rest score was 18 LV cavity was dilated and RV cavity was visualized. INTERPRETATION: Myocardial infarction with no viability of apex, anteroapical, inferoapical,and apicolateral segments. Myocardial infarction with peri-infarct ischemia of the mid anterior,and mid inferior segments as well as inferolateral wall. Akinesia of apex and apical segments ,and hypokinesia of the inferior and inferolateral walls. 6) StressLVEF=33% & Rest LVEF=45% (myocardial stunning) 7) SSS= 25 SDS=7 8) LV cavity dilatation & RV visualization. (The scan pattern is in favor of LAD & LCX involvement , The patient is in high risk category)

Other Indices Assessed by MPI: Increased lung uptake of thallium.(L/H) Stress-induced ventricular dilatation (TID). Increased RV uptake

Transient Ischemic Dilatation (TID)

RV visualization

LV cavity was dilated and RV cavity was visualized. GHAEM HOSPITAL NUCLEAR MEDICINE DEPARTMENT RE: Mr. 92/1/20 GATED MYOCARDIAL PERFUSION SPECT: After IV injection of 0.568mg/kg of Dipyridamole, 20mCi of Tc-99m-MIBI was injected intravenously and scanning was performed in supine & prone positions and using gated SPECT technique. On the other day, the rest phase was performed with the same protocol. The scan showed absent tracer uptake in the apex, anteroapical, inferoapical ,and apicolateral segments with no improvement in the rest phase. The scan also showed decreased tracer uptake in the mid anterior, and mid inferior segments as well as inferolateral wall with partial improvement in the rest phase. On the gated SPECT images akinesia of apex and apical segments , and hypokinesia of the inferior and inferolateral walls were noted. Calculated stress-LVEF was 33% and rest-EF was 45%. Summed stress score was 25 and summed rest score was 18 LV cavity was dilated and RV cavity was visualized. INTERPRETATION: Myocardial infarction with no viability of apex, anteroapical, inferoapical,and apicolateral segments. Myocardial infarction with peri-infarct ischemia of the mid anterior,and mid inferior segments as well as inferolateral wall. Akinesia of apex and apical segments ,and hypokinesia of the inferior and inferolateral walls. 6) StressLVEF=33% & Rest LVEF=45% (myocardial stunning) 7) SSS= 25 SDS=7 8) LV cavity dilatation & RV visualization. (The scan pattern is in favor of LAD & LCX involvement , The patient is in high risk category)

Pre-operative risk assessment before Non-cardiac surgery

GHAEM HOSPITAL NUCLEAR MEDICINE DEPARTMENT RE: Mr. 92/1/20 GATED MYOCARDIAL PERFUSION SPECT: After IV injection of 0.568mg/kg of Dipyridamole, 20mCi of Tc-99m-MIBI was injected intravenously and scanning was performed in supine & prone positions and using gated SPECT technique. On the other day, the rest phase was performed with the same protocol. The scan showed absent tracer uptake in the apex, anteroapical, inferoapical ,and apicolateral segments with no improvement in the rest phase. The scan also showed decreased tracer uptake in the mid anterior, and mid inferior segments as well as inferolateral wall with partial improvement in the rest phase. On the gated SPECT images akinesia of apex and apical segments , and hypokinesia of the inferior and inferolateral walls were noted. Calculated stress-LVEF was 33% and rest-EF was 45%. Summed stress score was 25 and summed rest score was 18 LV cavity was dilated and RV cavity was visualized. INTERPRETATION: Myocardial infarction with no viability of apex, anteroapical, inferoapical,and apicolateral segments. Myocardial infarction with peri-infarct ischemia of the mid anterior,and mid inferior segments as well as inferolateral wall. Akinesia of apex and apical segments ,and hypokinesia of the inferior and inferolateral walls. 6) StressLVEF=33% & Rest LVEF=45% (myocardial stunning) 7) SSS= 25 SDS=7 8) LV cavity dilatation & RV visualization. (The scan pattern is in favor of LAD & LCX involvement , The patient is in high risk category)

Recent Studies: (1) Long-term prognostic value of exercise technetium-99m tetrofosmin myocardial perfusion single-photon emission computed tomography. in 655 consecutive patients exercise (99m)Tc-tetrofosmin SPECT provided prognostic information incremental to clinical data and exercise test data. The SPECT parameters abnormal scan, reversible defect, and summed rest score were strong predictors of long-term outcome. J Nucl Cardiol.2012 Oct;19(5)

Recent Studies: (2) Risk stratification of CAD with SPECT-MPI in women with known estrogen status. 2,194 women with an intermediate to high CAD pre-test risk Gated SPECT-MPI provides risk stratification beyond standard exercise stress testing for women with suspected coronary artery disease, especially in patients with intermediate DTS and is independent of ES. J. Nucl. Cardiol. 2012 Apr;19(2)

What is the risk of a Normal MPI? In 20963 Pts with normal 201Tl-MPI from 16 studies, followed for a mean of 28.3 months, the death or non-fatal MI rate averaged about 0.7% /year. In 12000 pts from 14 studies with 99mTc-MIBI, Hard event rate was 0.6%. A meta-analysis, including 19 studies of >39 000 patients with an average of 2.3 years of follow-up, the event rate with a negative SPECT MPI was 0.6%. Circulation 2003; 1404-18 J Nucl Med 2003 ; 648 J Nucl Cardiol. 2004; 11: 171–185.

How long a MPI result is valid? Warranty period Normally: 1.5-2 yrs In patients without previous CAD the level of risk was uniform with time. In patients with known CAD, risk increased with time (e.g., risk in the first year was less than in the second year, hence, a dynamic temporal component of risk was present).

When the repeat imaging is indicated? AUC: New symptoms or Worsening

Conclusion Gated SPECT is the best modality for prognostic stratification. Normal MPI SPECT means low risk irrespective of results of other modalities. Different perfusion and function indices assessed by MPI have incremental value in risk stratification.

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