What is Cardiac Positron Emission Tomography (PET)?
Positron emission tomography (PET) is a nuclear medicine imaging technique that produces a three-dimensional image of functional processes in the body by detecting pairs of gamma rays emitted indirectly by a positron emitting radiotracer.
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What is the PET Stress and Rest Myocardial Perfusion Scan?
This is a non-invasive imaging technique that evaluates blood flow to the heart muscle. The blood flow to the heart muscle is reduced in the narrowed/disease coronary arteries. This will lead to reduction of oxygen supply to the involved heart muscle and producing symptoms like chest discomfort or shortness of breath.
A small amount of radioactive medication will be administered through your IV line during the test. The amount of radiation exposure is extremely low, as compared to the quality of information gained from having the PET scan performed. Your doctor will explain the benefits and any risks prior to the exam.
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PET Stress and Rest Myocardial Perfusion Scan with Rubidium-82
Rubidium-82 is a positron emitting radiotracer with a physical half-life of 75seconds. It is administered into the human body intravenously. Following intravenous administration, Rb-82 is an analog to potassium and rapidly taken up by heart muscle. In human studies, Rb-82 activity was noted in the heart within the first minute of injection. The uptake of Rb-82 by the heart muscle is related to the blood flow. Therefore, areas of the heart with adequate blood flow would have more Rb-82 activity in comparison to those areas with compromise blood flow. A PET scanning camera takes three dimensional images of Rb-82 uptake by the heart. Further analysis of these images helps to identify the location, severity and extent of reduced blood flow to the heart muscle (ischaemia).
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How is PET Myocardial Perfusion Scan with Rubidium-82 performed?
  • Typically, the entire exam takes less than one hour.
  • An IV line will be placed in your arm to allow the administration of medication.
  • Your blood pressure and heart rate will be recorded at intervals during the exam and small electrodes will be placed on your chest to monitor your heart.
  • You will lie on a special scanning table.
  • A small amount of radioactive medication will be given through the IV line that will allow the PET camera to take pictures of your heart and detect changes in blood flow.
  • The PET camera will take pictures in two cycles:
    • At rest
    • At stress (increased workload of the heart)
  • Once your Cardiac PET scan is complete, you may resume normal activities.
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How long does the PET Stress and Rest Myocardial Perfusion Scan with Rubidium-82 take?
The whole procedure including the rest/stress scans and the pharmacological stress test of the heart takes less than 60 minutes.
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How do you prepare for the procedure?
Please arrive at 15minutes prior to your appointment so that we can have adequate time to prepare to the Rb-82 and the medication for pharmacological stress test. If you are not able to come for the procedure, please inform us in advance.
Please take note of the following:
  • You can have a light meal 1hour prior to the procedure.
  • 24hours before the procedure, please AVOID the following:
    • Any products that contain Caffeine, such as tea, coffee, cocoa and milo.
    • Any products that contain Chocolates, including candies, frosting, cookies, and chocolate milk.
    • Any soft drinks that contain Caffeine, such as Coke, and including those labeled “Caffeine-free”.
  • 48hours before the procedure, you should not take Persantin or Theophylline-contained medication.
  • Please bring along a list of all your medications.
  • ** ASTHMA-CAUTION. The use of stress agent (Persantin) is generally avoided in patient with asthma. Please be sure and inform your physician and the staff if you have history of asthma, bronchitis or emphysema.
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What are the advantages of PET myocardial perfusion scan with Rb-82 when compared with the conventional SPECT muocardial perfusion scan?
  • The image quality of PET is better than conventional SPECT scan. PET has been shown to yield higher total image counts compared with SPECT. Moreover, PET provides reduced attenuation correction.
  • Due to the myocardial extraction fraction, tracer kinetics, and physical half-life of SPECT tracers, the stress images obtained using SPECT are actually post-stress. PET offers true stress data because the images are acquired while the myocardium is in a state of peak hyperemia.
  • For PET myocardial perfusion scan with Rb-82, the total body exposure to radiation is much lesser than the conventional SPECT scan due to short physical half-life of Rb-82, which is only 75seconds.
  • For PET myocardial perfusion scan with Rb-82, the entire procedure takes about 30 – 40minutes. While the procedure for the conventional SPECT myocardial perfusion scan would at least take 4 – 6 hours to complete.
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What is the sensitivity and specificity of PET myocardial perfusion scan with Rb-82?
Studies performed in 855 patients have shown a high sensitivity of 95% and specificity of 95%.
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What is the risk involved in the PET myocardial perfusion scan with Rb-82?
Radiation exposure is minimal due to short half-life of Rb-82. (72 seconds) However, this procedure should not be done on a pregnant woman. Please inform us if you think you are pregnant.
  • No adverse reactions specifically attributable to Rb-82 have been reported.
  • Adenosine/Dipyridamole are agents that dilate blood vessels not only in the heart but also in the rest of the body. Therefore, it is common to feel hot, flushing and warm. Many people may have headache or abdominal pain, while few may feel nausea, particularly with Dipyridamole The effect of Dipyridamole may last up to 30minutes, while of Adenosine subsides immediately due to short life of 10seconds only. The side-effects of dipyridamole can be reversed by aminophylline (an anti-asthma medication).
  • The risk of an adverse event such as heart attack is approximately in 1 in 10,000, but certain contraindications exist and this test should NOT be ordered for patients who have:
    • Suffered a heart attack in the previous 2 days
    • Unstable angina
    • Uncontrolled arrhythmias, or abnormal heart rhythms
    • Severe symptomatic aortic heart valve disease
    • Uncontrolled heart failure
    • Infection or inflammation of the heart
    • Acute aortic dissection
    • Acute pulmonary embolism
We use pharmacologic stress with Dipyridamole for patients. We do a set of images while a patient is at rest and subsequently stress them with Dipyridamole infusion. At peak vasodilation, we give them another dose of the isotope and compare what the perfusion is at stress versus rest. If the stress image shows a defect that isn’t there at rest, then that is ischemia. If it’s abnormal at rest, it could be a scar from a previous heart attack.
  • We are always looking for normal versus scar versus ischemia. We do both rest and stress PET on the same day by our protocol.
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What happens after the procedure?
  • Drink plenty of water to assist in the elimination of the radiotracer from your body.
  • You should resume your regular daily activities after the procedure. If you were asked to temporarily stop taking any medication prior to the procedure, be sure to ask when you should resume taking your medications.
  • Your results will be given to your personal doctor after the nuclear medicine physician / cardiologist has reviewed your images and prepared a written report.
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Calcium Scoring Overview
A calcium score will be done after the stress scan. Coronary calcium is a marker for plaque (fatty deposits) in a blood vessel or atherosclerosis (hardening of the arteries). The presence and amount of calcium detected in a coronary artery by CT scan, indicates the presence and amount of atherosclerosis plaque.
A calcium score is computed based upon the volume and density of the calcium deposits. It does not correspond directly to the percentage of narrowing in the artery but does correlate with the severity of the underlying coronary atherosclerosis.
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How does the nuclear stress cardiac perfusion study help decide on my management, clinical decision and ultimate outcome?
The blockage is important and now they are doing CT angiography to see the blood vessels. But the anatomy isn’t always the answer. The physiology is even more important because if somebody has a partial blockage, but there is no evidence of ischemia on a good test physiologically, like SPECT or PET, then they don't need any intervention because whatever the degree of anatomic change, it isn’t really causing the patient a perfusion abnormality.
There was the END study (Economics of Noninvasive Diagnosis) that was published several years ago. It looked at several thousand patients with chest pain. Half of them went right to the cath/Angiography lab, and the other half had a SPECT/MIBI study. The decision of whether to have the invasive angiography hinged on the results of your mibi scan. The patients who had the invasive test didn’t do any better than those that had the scan first. So, there’s no improved outcome by taking the patient right to the cath lab, and the expense on the patients that have the angiogram was far greater.
We send patients to the catheterization/angiogram lab if they showed they have moderate amount of inducible ischemia. The point of it was that it makes more sense to do the non-invasive test; patients do just as well, and the test helps predict whether they need coronary angiography and any other test down the line.
Dr Nico Pijls (Catharina Hospital, Eindhoven, the Netherlands).
"If you have a lesion that isn't causing ischemia, the intrinsic risk of the stenosis is very low, lower than the risk of placing the stent," Because interventionalists can't discriminate by angiogram which lesions are causing ischemia, "we place stents everywhere, and the benefits of placing the stent in the right position is countered by the damage we do by placing stents where it is not necessary."
Dr William Boden (Buffalo General Hospital, NY), told heartwire that the results show that a physiologic assessment of stenosis is much better than what the eye can detect."There are some arteries that don't look that narrow, which you can avoid," he said. "Conversely, there are other borderline lesions that turn out to be functionally significant because there is a gradient with FFR. This is important, because it will help to really streamline practice, to help avoid unnecessary PCI in some vessels that shouldn't be fixed. It will also selectively target the really diseased vessels that would benefit from PCI."
Dr Ajay Kirtane (Columbia University, New York, NY) told heartwire that the findings emphasize treating the patient and the ischemia and leaving the other vessels alone. "Treating lesions that don't need to be treated is not a good thing and can harm people, but treating lesions that need to be treated is also beneficial over leaving them alone," said Kirtane. In the COURAGE nuclear substudy, for example, patients with flow-limiting lesions left to medical therapy fared worse than those treated with PCI, findings that are supported by the DEFER study.
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References :
  • Interrelation of Coronary Calcification, Myocardial Ischemia, and Outcomes in Patients With Intermediate Likelihood of Coronary Artery Disease. A Combined Positron Emission Tomography/Computed Tomography Study Matthew P. Schenker, Sharmila Dorbala, Eric Cho Tek Hong, Frank J. Rybicki, Rory Hachamovitch, Raymond Y. Kwong, and Marcelo F. Di CarliCirculation published 2008 Apr 1; 117(13): 1693-700.
  • Complementary roles in Hybrid cardiac imaging; two perspectives, one patient.
    Eric C T Hong, MD, Kimura Eric, MD, Sharmila Dorbala, MBBS, Marcelo F. Di Carli, MD
    J Nucl Cardiol. 2007 Jul 14(4): 617-20. Epub 2007 Jun 14
  • Shaw LJ, Berman DS, Maron DJ, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation 2008;117:1283-1291.
  • Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol 2004;11:171-185.
  • Beller GA, Zaret BL. Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease. Circulation 2000;101:1465-1478.
  • Davies RF, Goldberg AD, Forman S, et al. Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization. Circulation 1997;95:2037-2043.
  • Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516. 
  • Pijls NH, van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol 2007;49:2105-2111.
  • Topol EJ, Nissen SE. Our preoccupation with coronary luminology: the dissociation between clinical and angiographic findings in ischemic heart disease. Circulation 1995;92:2333-2342.
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