TOPIC 15. Radionuclide diagnostics of the cardio-vascular system.

Radiocardiography, myocardium visualisation.

Introduction
Nuclear studies involve injection with a small amount of radioactive imaging agent and
monitoring the progress of the agent through the heart and vascular system using a special
type of camera. Two of the most common procedures are the thallium stress test and the
multi-gated analysis study (MUGA study).
There are two main types of nuclear tests performed in cardiology:
1) Myocardial perfusion studies- examines the blood flow to the heart muscle.
2) Dynamic studies- measures the contractile (pumping) function of the heart muscle.
Exercise Myocardial Perfusion Imaging:
This test is performed with the isotope thallium or, at the present time, more often with
technetium Sestamibi (MIBI). The test is performed in conjunction with a treadmill
exercise test and is referred to as a "treadmill-thallium" test or a "treadmill-MIBI" test.
Myocardial perfusion imaging is performed:
 unexplained chest pain
 chest pain brought on by exercise (called angina)
 when the results of a routine treadmill study are equivocal
 to evaluate the presence and extent of suspected or known coronary artery disease
 In some patients to determine the functional significance of coronary blockage
observed on an angiogram
 to determine if coronary disease is the cause of abnormalities on the resting
electrocardiogram
 to visualize blood flow patterns to the heart walls, called a myocardial perfusion
scan
 to determine the extent of injury to the heart following a heart attack, or myocardial
infarction
 to evaluate the results of bypass surgery or other revascularization procedures
designed to restore blood supply to the heart
 in conjunction with an electrocardiogram (ECG), to evaluate heart-wall movement
and overall heart function with a technique called cardiac gating (MUGA)

A thallium stress test evaluates the blood flow to the heart muscle in stress and rest
conditions. The imaging agent is injected at peak stress and follows the blood flow to the
muscle tissue.
Procedure: The thallium test has two parts, stress imaging in the morning and rest imaging
in the afternoon. Depending upon the type of exam ordered, the first part may involve
walking on a treadmill or pedaling a stationary bicycle for a few minutes to increase the
workload on the heart. While the exercise, the electrical activity of the heart will be
monitored by electrocardiography (ECG) and blood pressure will be frequently measured.
The patient will be asked to exercise until he is too tired to continue or short of breath, or
if he experiences chest pain, leg pain, or other discomfort. When blood flow to the heart
has reached its peak, patient will be given the radiotracer (radioactive thallium) IV.
The most frequent exercise stress test endpoints sufficient to stop the test are: fatigue,
dyspnea, chest pain, ST-depression, arrhythmia.
 Patients who are unable to exercise are given a drug that increases blood flow to the
heart. One minute later, patient will stop exercising and will be positioned on a moveable
examination table. Thallium will follow the blood flow to the heart and concentrate in
certain areas of the muscle. The radioactive energy of radiotracer is detected by a gamma
camera, a PET scanner or probe. The patient should be monitored by nuclear cardiac
imaging to see where the thallium has concentrated. The process will take about 40
minutes.
After stress imaging patient waits 3-4 hours and returns for rest imaging. Stress images
will be compared with images of the resting heart. Actual scanning time for each heart
scan varies from 25 to 40 minutes depending on the type of scanner used.
In some centers, nuclear medicine images can be superimposed with CT or magnetic
resonance imaging (MRI) to produce special views, a practice known as image fusion or
co-registration.

Learning objectives
- Radionuclide diagnostics of the cardio-vascular system
- Radiocardiography
- Myocardium visualisation

Self-control tests
1. Select RPL that is used for visualization of the unchanged myocardium.
A. Au-198
B. Tl – 201
C. Tc-99m pyrophosphate
D. I-131 hippuran
E. Tc-99m bound with human plasma albumin

2. Select the method that is used for detection of acute myocardial infarction
A. exercise with Tl-201
B. Xenon inhalation
C. injection of human plasma albumin labeled with I-131
D. scintigraphy with Tc-99m pyrophosphate
E. nothing from abovementioned
3. Select radionuclide that accumulate in the zone of ischemia in case of myocardial
infarction
A. Na-24
B. Tl-201
C. Fe-59
D. Tc-99m- pyrophosphate
E. nothing from abovementioned

4. Select the main method of Tl-201 administration for myocardial scintigraphy

A. subcutaneous
B. i/v
C. per os
D. intramuscular
E. inhalation

5. Select normal value of LV EF

A. 15-25
B. 35-35
C. 50-60
D. 75-85
E. 85-90

References
1. Encyclopedia of Diagnostic Imaging by Albert L. Baert (Hardcover - Feb 13, 2008)
2. Grainger & Allison's Diagnostic Radiology: Multiple Choice Questions by Adam
Mitchell (Paperback - Dec 12, 2003)
3. Radiology: PreTest Self-Assessment and Review by David M., M.D. Hovsepian
(Paperback - Jun 1, 1993)
4. Radiology Super Secrets (Secrets Ser) by Douglas S., M.D. Katz, Kevin R., M.D.
Math, Stuart A. Groskin, and Math Groskin Katz (Audio CD - May 1999)
5. Radiology Imaging: Words And Phrases by Sally C. Pitman (Paperback - Aug 30,
2005)