Circulation Journal

Official Journal of the Japanese Circulation Society

ORIGINAL ARTICLE
http://www. j-circ.or.jp Imaging

Comparison of Myocardial Perfusion Imaging Between

the New High-Speed Gamma Camera and
the Standard Anger Camera
Hirokazu Tanaka, MD; Taishiro Chikamori, MD; Satoshi Hida, MD; Kenji Uchida;
Yuko Igarashi, MD; Tsuyoshi Yokoyama; Masaki Takahashi; Chie Shiba, MD;
Mana Yoshimura, MD; Koichi Tokuuye, MD; Akira Yamashina, MD

Background: Cadmium-zinc-telluride (CZT) solid-state detectors have been recently introduced into the field of
myocardial perfusion imaging. The aim of this study was to prospectively compare the diagnostic performance of
the CZT high-speed gamma camera (Discovery NM 530c) with that of the standard 3-head gamma camera in the
same group of patients.

Methods and Results: The study group consisted of 150 consecutive patients who underwent a 1-day stress-rest
99 mTc-sestamibi or tetrofosmin imaging protocol. Image acquisition was performed first on a standard gamma cam-

era with a 15-min scan time each for stress and for rest. All scans were immediately repeated on a CZT camera with
a 5-min scan time for stress and a 3-min scan time for rest, using list mode. The correlations between the CZT
camera and the standard camera for perfusion and function analyses were strong within narrow Bland-Altman limits
of agreement. Using list mode analysis, image quality for stress was rated as good or excellent in 97% of the 3-min
scans, and in 100% of the ≥4-min scans. For CZT scans at rest, similarly, image quality was rated as good or excel-
lent in 94% of the 1-min scans, and in 100% of the ≥2-min scans.

Conclusions: The novel CZT camera provides excellent image quality, which is equivalent to standard myocardial
single-photon emission computed tomography, despite a short scan time of less than half of the standard time.  
(Circ J 2013; 77: 1009 – 1017)

Key Words: Cadmium-zinc-telluride detector; Coronary artery disease; Scan time; Single-photon emission com-
puted tomography

C
admium-zinc-telluride (CZT) solid-state detectors
have recently been introduced into the field of myo-
cardial perfusion imaging (MPI).1–3 In this camera,
the conventional sodium iodide crystals have been replaced
by CZT semiconductors, which directly convert radiation into
electric signals.4 Energy resolution and spatial resolution have
been significantly improved, and reduction of acquisition time
or radiotracer dose has been reported from the USA and Eu-
rope.5–7 Although these observations regarding this new tech-
nology are promising,8 the image quality of the CZT high-
speed gamma camera has not yet been fully evaluated in the
Japanese population in comparison to standard single-photon
emission computed tomography (SPECT) with an Anger cam-
era, which is used in almost all Japanese institutions. Thus, we
prospectively compared image quality of the CZT high-speed
solid-state SPECT camera (Discovery NM 530c) with a stan-
dard 3-head gamma camera using 360°-arc acquisition in the
same group of patients. In addition to the short scan time set
initially for the CZT gamma camera, the possibility of further
reduction of the scan time was also evaluated with the use of
list files with this new SPECT system.
Methods
Subjects
The subjects consisted of 150 patients (102 men and 48 women;
mean age, 71±10 years) with suspected or known coronary
artery disease (based on clinical symptoms, coronary risk pro-
files, electrocardiographic findings or past medical history)
who also gave written informed consent to participate in this
study between September 2011 and December 2011. Previous
myocardial infarction had occurred in 46 patients. Patients with

Received August 22, 2012; revised manuscript received October 18, 2012; accepted November 27, 2012; released online December 26, 2012  
Time for primary review: 16 days
Department of Cardiology (H.T., T.C., S.H., Y.I., C.S., A.Y.), Department of Radiology (K.U., T.Y., M.T., M.Y., K.T.), Tokyo Medical
University, Tokyo, Japan
Mailing address: Hirokazu Tanaka, MD, Department of Cardiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo
160-0023, Japan.   E-mail: htanaka7@tokyo-med.ac.jp
ISSN-1346-9843  doi: 10.1253/circj.CJ-12-1093
All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp

Circulation Journal Vol.77, April 2013

1010
Figure 1.   Study protocol for stress myocardial perfusion imaging. AC, Anger camera; ATP, adenosine triphosphate disodium;
CZT, cadmium-zinc-telluride camera.
acute myocardial infarction or unstable angina within 1 month
before the study and those with advanced atrioventricular block
were excluded. This prospective study was approved by the
Ethics Committee of Tokyo Medical University (No. 1739).
Stress MPI
The study protocol of stress MPI with the use of 2 gamma
camera systems is shown in Figure 1. MPI during exercise
with 99 mTc-sestamibi or tetrofosmin was obtained in 54 pa-
tients using the 1-day protocol. Patients performed symptom-
limited multistep exercise using a bicycle ergometer.9,10 99 mTc-
sestamibi (370 MBq) or 99 mTc-tetrofosmin (296 MBq) was
given when a sub-maximal heart rate, chest pain, or ST-seg-
ment depression of ≥0.1 mV, or leg fatigue developed. Exer-
cise was then continued for 1 min at the same level as before.
Sixty min after this last session of exercise, electrocardiogram-
gated SPECT was acquired. Four hours after that, the patients
were given 99 mTc-sestamibi or tetrofosmin (740 MBq) while at
rest. Sixty min later, electrocardiogram-gated SPECT image
acquisition began.
Adenosine triphosphate disodium (ATP) loading MPI with
99 mTc-sestamibi or tetrofosmin was performed in 96 patients
using the 1-day protocol. Patients were instructed not to con-
sume caffeine for 12 h before the test. ATP (0.16 mg · kg−1 · min−1)
was given i.v. for 6 min.11,12 Three minutes after ATP, 99 mTc-
sestamibi or tetrofosmin (296−370 MBq) was given i.v., and
imaging was started 60 min later. After 4 h, the patients were
given 99 mTc-sestamibi or tetrofosmin (740 MBq) while at rest.
Sixty min later, electrocardiogram-gated myocardial SPECT
was performed. The estimated total radiation exposure with
this protocol was 9.00−9.58 mSv.
The first data were acquired with a 3-detector gamma cam-
era system (Prism 3000XP or Prism IRIX; Picker, Cleveland,
OH, USA) over a 360° arc (in 6°-wide directions, taking 45 s
per projection, 20 times). The scan time was 15 min after stress
and at rest. A low-energy high-resolution parallel multihole
collimator was used. The maximum matrix size was 64×64.
When obtaining electrocardiogram-gated images, the R-R in-
terval was divided by the R wave trigger into 8 equal portions.
End-diastolic and end-systolic MPI was obtained with this
Circulation Journal Vol.77, April 2013
TANAKA H et al.
method. One hundred and thirty-one of 150 patients (87%)
were in sinus rhythm during image acquisition. SPECT images
were reconstructed from the data with a data processor (Odys-
sey VP, Picker) combined with a Butterworth filter (order 8;
cut-off frequency 0.25) and a ramp filter.
Immediately after the completion of the first data acquisi-
tion using the standard Anger camera, the second data were
acquired in list mode using the high-speed CZT camera with
pinhole collimation (Discovery NM 530c; GE Healthcare,
Haifa, Israel).4,13 This new gamma camera is equipped with a
multiple-pinhole collimator and 19 stationary CZT detectors
that simultaneously focus on the heart to maximize the effi-
ciency of SPECT. The stationary array simultaneously acquires
all the views necessary for tomographic reconstruction, saving
the time required by conventional cameras for acquisitions
while rotating around the subjects.14 Stress and rest scans were
acquired in 5 min and 3 min, respectively, and data were col-
lected as a list file with scan times of 1−5 min. SPECT images
were reconstructed on the workstation (Xeleris, GE Healthcare)
using a new dedicated iterative algorithm with integrated col-
limator geometric modeling, using maximum penalized likeli-
hood iterative reconstruction to obtain perfusion images in
standard axes.3,15 For image reconstruction, 40 iterations were
performed for stress and 50 iterations for rest. A Butterworth
filter (order 7; cut-off frequency 0.41) was applied to the recon-
structed slices. When obtaining electrocardiogram-gated im-
ages, the R-R interval was divided by the R wave trigger into 8
equal portions. No scatter or attenuation corrections were made.
After the completion of 2 sessions of data acquisition, par-
ticipants completed a questionnaire about their preference of
study protocol for each gamma camera and of assigned cam-
era for the next MPI session.
Image Analysis
Image quality was graded visually on a 4-point scale as 1, poor;
2, fair; 3, good; or 4, excellent, based on myocardial count
density, uniformity, myocardial edge definition, visualization,
and background noise.5 Left ventricular (LV) myocardial activ-
ity was measured using a semi-automatically drawn region of
interest around the LV myocardium with the use of the vertical
New High-Speed SPECT
long-axis view of the SPECT image on the Xeleris from the list
file of 1−5 min.
In accordance with a previous method, each SPECT image
was divided into 17 segments.16 The radiopharmaceutical ac-
cumulation in the myocardium was visually evaluated by 2
cardiologists (blinded to clinical data) using a 5-point scale: 0,
normal; 1, slight reduction of uptake; 2, moderate reduction of
uptake; 3, severe reduction of uptake; or 4, absence of radioac-
tive uptake. The total of the scores for all the segments during
exercise and at rest was designated as the summed stress
scores (SSS) and the summed rest scores (SRS), respectively.
SSS minus SRS was defined as the summed difference score
(SDS).11 Disagreements in image interpretation were resolved
by consensus after extensive discussion.
Each reconstructed short-axis electrocardiogram-gated
SPECT image at the 3-min scan time at rest was processed,
and LV functional parameters (LV end-diastolic volume, LV
end-systolic volume and LV ejection fraction) were automati-
cally obtained as described by Germano et al.17
Statistical Analysis
Results are expressed as mean ± SD. To assess reproducibility
for perfusion and functional indices derived from the CZT and
standard gamma cameras, Spearman’s correlation and Bland-
Altman analysis with limits of agreement were used. The κ
statistic was also used to compare the concordance of the inter-
pretation of myocardial perfusion in a 17-segment model be-
tween the CZT and standard cameras. P<0.05 was considered
to indicate a statistically significant difference. Statistical com-
putations were performed using SPSS 11.0 (SPSS, Chicago,
IL, USA) and MedCalc 11.4 (MedCalc Software, Mariakerke,
Belgium).
Results
Patient Characteristics and Response to Examinations
The mean patient age was 71 years, and two-thirds were men
(Table 1). The mean body mass index was 23 kg/m2. Among
classical coronary risk factors, the prevalence of hypertension
was the highest, and that of diabetes mellitus was 35%. During
stress MPI, 99 mTc-sestamibi was used in 91 patients and 99 mTc-
tetrofosmin in 59. All of the 150 patients underwent stress MPI
using both the standard and CZT gamma cameras successfully.
Of these, 113 patients (75%) preferred the CZT camera to the
standard camera in this protocol. In addition, 119 patients
(79%) indicated their preference for the CZT camera for the
next assignment of MPI.
Quality of CZT Gamma Camera SPECT Imaging
Quality of SPECT image acquired with the high-speed CZT
camera according to scan time is shown in Figure 2. In the
post-stress acquisition at the dose of 296−370 MBq, the preva-
lence of excellent/good ratings for SPECT image increased
rapidly. At the 3-min scan time, the prevalence of high-quali-
ty image reached 97% (Figure 2A). In the acquisition at rest
using 740 MBq of 99 mTc-sestamibi or tetrofosmin, the preva-
lence of high-quality image was already 94% at the 1-min scan
time (Figure 2B).
The LV technetium activity increased linearly as the scan
time progressed (Figures 2C,D). With LV technetium activ-
ity of ≥6,000,000 counts, 94% of myocardial SPECT images
were rated as excellent/good.
Comparison of MPI Between the CZT and Standard Cameras
The summed scores (SSS, SRS and SDS) obtained either by
Circulation Journal Vol.77, April 2013
1011
Table 1. Clinical Patient Characteristics (n=150)
Age (years) 71±10
Gender (M/F) [%] 102/48 [68/32]
Height (cm) 161±9
Body weight (kg) 60±12
Body mass index (kg/m2) 23±3
Risk factors
  Hypertension 113 (75)
  Diabetes mellitus 53 (35)
  Dyslipidemia 93 (62)
  Smoking 59 (39)
Prior MI 46 (31)
Prior PCI 58 (39)
Prior CABG 7 (6)
Type of stress (Exercise/ATP) [%] 54/96 [36/64]
Radiotracer (99mTc-sestamibi/99mTc-tetrofosmin) [%] 91/59 [61/39]
Data given as mean ± SD or n (%).
ATP, adenosine triphosphate disodium; CABG, coronary artery
bypass grafting; MI, myocardial infarction; PCI, percutaneous
coronary intervention.
the CZT camera or the standard Anger camera were compared
using linear regression analysis (Figure 3). Strongly positive
correlations of 0.83−0.95 were observed. Bland-Altman limits
of agreement for summed scores were −3.8 to 5.7 for SSS,
−3.4 to 5.0 for SRS and −2.7 to 3.0 for SDS (Figure 3).
In 139 patients (93%) who successfully completed LV
functional analysis with electrocardiogram-gated SPECT, lin-
ear regression analysis was performed to compare the func-
tional parameters (LV end-diastolic volume, LV end-systolic
volume, LV ejection fraction) at rest between the CZT at the
3-min scan time and the standard Anger camera acquisitions.
This analysis produced strongly positive correlations of 0.93−
0.98 (Figure 4). Bland-Altman limits of agreement were −16.7
to 9.8 for LV end-diastolic volume, −14.2 to 9.4 for LV end-
systolic volume, and −7.7 to 12.1 for LV ejection fraction
(Figure 4). An example of MPI taken by both the CZT and
standard cameras in a patient with previous myocardial infarc-
tion and 3-vessel disease is shown in Figure 5.
Per-segment analysis was judged with the use of a 17-seg-
ment model, and a total of 2,550 segments in 150 patients were
analyzed using the κ statistic (Table 2). This showed a strong
concordance (κ=0.815) for perfusion analysis on a per-segment
basis, either acquired with the CZT or standard Anger camera.
When these segments were categorized based on the 3 coro-
nary territories, however, the concordance rate decreased, par-
ticularly in the right coronary territory. In the segment related
to the right coronary artery, a greater number of segments were
rated as having more severe defects with the CZT camera as
compared with the standard Anger camera (Table 2).
Discussion
We set out to determine whether the quality of MPI using a
novel high-speed CZT camera with a short scan time of less
than half that of the Anger camera, which usually requires a
15-min scan time, was comparable to that using the standard
method in the Japanese population. With the scan time of
5 min after stress and 3 min at rest, the image quality of MPI
was rated as excellent using the CZT gamma camera in 150
Japanese patients with suspected or known coronary artery
disease. A further reduction in the scan time of 1 or 2 min may
1012 TANAKA H et al.

Figure 2.  Image quality and the average of acquired counts in the field of view using the cadmium-zinc-telluride camera accord-
ing to scan time. The prevalence of excellent/good rating for single-photon emission computed tomography image increased with
prolonged scan time, but no further improvement appears after the scan duration of (A) 3 min is reached for stress imaging and
(B) 2 min for rest imaging. The average of acquired counts increased linearly as the scan time progressed in (C) stress imaging
and (D) rest imaging. Results are expressed as box-and-whisker plots; the central box covers the interquartile range, with the
median indicated by the line within the box. The whiskers extend to the most extreme values within 1.5 interquartile ranges. More
extreme values are plotted individually.

also be possible based on the image quality derived from the
list data. As a trade-off for acquisition time, that is, using
longer acquisition time, dose reduction of 99 mTc-sestamibi or
tetrofosmin is also possible. In addition, the majority of the
patients preferred the CZT camera for the next assignment of
MPI. These observations were consistent with early reports
from the USA and Europe, where the body size of patients are
usually larger than that of Japanese patients.5,6,18 We also pro-
spectively compared the perfusion abnormality of the SPECT
image and LV functional analysis in the same patients between
the CZT camera and the Anger camera with a 360° arc ac-
quisition. The correlation coefficients for summed scores and
LV functional parameters between the 2 measurements were
strongly positive (r=0.81 to r=0.94; Figure 3). In addition, the
Bland-Altman method showed an almost null bias and accept-
able limits of SD (Figure 3). Thus, the present study has
demonstrated an advancement in this new SPECT technology
regarding fast data collection without loss of image quality;
this technology is also favored by the Japanese patients.
Comparison With Previous Studies
A limited number of studies have compared image quality of
the CZT camera and the Anger camera in the same patients.
Using a Ventri dual-head camera over a 180° arc acquisition for
15 min, Herzog et al evaluated percentage tracer uptake in the
3 coronary territories in 20 subjects.5 Applying linear regres-

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New High-Speed SPECT 1013

Figure 3.  (Left) Linear regression analysis and (Right) Bland-Altman plots for (A) summed stress score (SSS), (B) summed rest
score (SRS) and (C) summed difference score (SDS) between the cadmium-zinc-telluride (CZT) camera and standard Anger
camera (AC).

Circulation Journal Vol.77, April 2013

1014 TANAKA H et al.

Figure 4.  (Left) Linear regression analysis and (Right) Bland-Altman plots for (A) left ventricular (LV) end-diastolic volume
(LVEDV), (B) LV end-systolic volume (LVESV) and (C) LV ejection fraction (LVEF) between the cadmium-zinc-telluride (CZT) cam-
era and standard Anger camera (AC).

Circulation Journal Vol.77, April 2013

New High-Speed SPECT 1015

Figure 5.  Single-photon emission computed tomography (SPECT) and coronary angiography images of a 76-year-old man with
a history of anterior myocardial infarction. (A) The cadmium-zinc-telluride camera scans and (B) conventional SPECT images show
reversible perfusion defects of the antero-lateral and infero-posterior segments. (C) Coronary angiogram indicated 3-vessel coro-
nary artery disease with an intermediate stenosis of the left anterior descending coronary artery and left circumflex artery, and
severe narrowing of the right coronary artery and diagonal branches.

sion and Bland-Altman analyses, they reported good agree-
ments between the image taken with the standard Anger cam-
era and that taken with the CZT camera for 3 min after the
injection of 99 mTc-tetrofosmin of 300−350 MBq, or the image
acquired for 2 min using 99 mTc-tetrofosmin of 750−1,050 MBq.
Gimelli et al also used a dual-head gamma camera and CZT
camera applying a single-day standard protocol (370 MBq for
stress, 740 MBq for rest) in 34 patients with known or sus-
pected ischemic heart disease.18 They reported modest to good
agreements of percentage tracer uptake in individual coronary
territories between the image taken with the Anger camera and
the image taken with the CZT camera for a 5-min scan time

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1016 TANAKA H et al.

Table 2. Agreement of Per-Segment MP Scoring

Anger camera
Cadmium-zinc-telluride camera
0 1 2 3 4
Total: 2,550 segments (κ=0.815; agreement: 87.1%)
  0 2,024 92 4 2 0
  1 110 126 6 1 0
  2 6 52 34 4 0
  3 5 6 18 19 7
  4 2 0 3 12 17
LAD: 1,050 segments (κ=0.821; agreement: 90.1%)
  0 895 32 2 0 0
  1 29 33 2 0 0
  2 3 18 5 1 0
  3 3 2 7 5 3
  4 0 0 0 2 8
RCA: 750 segments (κ=0.774; agreement: 79.1%)
  0 484 53 1 0 0
  1 57 74 2 0 0
  2 0 20 24 1 0
  3 2 4 8 7 2
  4 1 0 3 3 4
LCX: 750 segments (κ=0.847; agreement: 90.8%)
  0 645 7 1 2 0
  1 24 19 2 1 0
  2 3 14 5 2 0
  3 0 0 3 7 2
  4 1 0 0 7 5
LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; MP, myocardial perfusion; RCA,
right coronary artery.

after stress and for a 4-min scan time at rest. In contrast to
perfusion analysis, strongly positive correlations were ob-
served in LV functional analysis such as for ejection fraction,
measured either with the Anger or CZT camera.12
In contrast to some of the aforementioned reports,5,18 we
evaluated a greater number of patients (n=150) with known or
suspected coronary artery disease using a 3-head gamma cam-
era system with a 15-min scan time as a standard. The dose of
99 mTc-tetrofosmin was lower, particularly at rest with 740 MBq
as compared with the previous studies, because the body size
of the Japanese patients was taken into account. Although the
study designs are different between the previous studies and the
present study, the results showing that this new CZT camera
facilitates fast data collection without loss of image quality, are
similar. Moreover, a further reduction of scan time or tracer
dose in MPI may be a reachable target in Japanese patients.
Possible Differences in SPECT Images Between the CZT
and Standard Anger Cameras
Regarding the per-segment analysis, we evaluated a 17-seg-
ment model including a total of 2,550 segments in 150 patients
with the use of the κ statistic, whereas the previous studies
assessed tracer uptake of only 3 coronary territories.3,12 The
current study showed a strong concordance (κ=0.815) in over-
all segments, but when these segments were categorized based
on the 3 coronary territories, the concordance rate decreased,
particularly in the right coronary territory (κ=0.774). In the
segment related to the right coronary artery, a greater number
of segments were rated as having more severe defects with the
CZT camera as compared with the standard Anger camera
(Table 2). Although the number of such discordant segments
was small, this result was somewhat worrisome. Askew et al
reported a reduced 99 mTc tracer uptake in the inferior wall,
particularly during the early acquisition started from 0 to
12 min after tracer injection.19 While many of the 19 pin-hole
CZT cameras are positioned in an array around the region of
the myocardium, some are positioned superior to the heart, but
oriented obliquely to look down at the myocardium; while
others are positioned inferior to the heart and angled oblique-
ly to look up at the myocardium.19 This arrangement may be
more sensitive to the presence of hepatic and bowel isotope
activity compared with the standard Anger camera with a 360°
arc acquisition. Another explanation may be attributed to the
difference between the 360° and 180° rotation method; the
latter is similar to the CZT camera system. Nakajima et al
reported that inferior segments showed lower isotope activity
in the 180° rotation than in the 360° rotation, particularly in
Japanese men.20 To reduce the aforementioned pseudo-abnor-
mality in the inferior wall, a modification of the study protocol,
such as prone acquisition, may be worth trying in the future.21
Study Limitations
In this prospective study, we did not perform coronary angio-
grams in all of the 150 patients. We recognize that the ultimate
goal in comparing the CZT and standard Anger cameras is to
evaluate the performance of these 2 SPECT systems in coro-
nary artery disease diagnosis, in reference to the results of
coronary angiogram. For example, it could be suggested that
the CZT camera might overestimate perfusion abnormalities,
looking closely at linear correlations between the summed
scores obtained from the CZT camera and those obtained from
the Anger camera (Figure 3). These non-significant trends,

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New High-Speed SPECT
however, need to be re-evaluated in relation to coronary anat-
omy. Until now, an adequate study protocol for the CZT cam-
era has not yet been defined for the Japanese population. This
is the reason why we set out initially to clarify whether the
quality of MPI using a novel high-speed CZT camera with a
short scan time of less than half that of the Anger camera, may
be comparable to that using the standard method. Now that a
study protocol using the CZT camera has been proposed for
the Japanese population, it is considered appropriate to move
on to the next step, that is, to evaluate the diagnostic perfor-
mance of this novel high-speed gamma camera in comparison
to invasive coronary angiography.
Conclusions
The novel high-speed CZT camera provides excellent image
quality, which is equivalent to standard myocardial SPECT,
despite a short scan time of less than half the standard time.
Acknowledgments
We are indebted to Dr Clifford A. Kolba (EdD, DO, MPH) and Associate
Professor Edward F. Barroga (PhD) of the Department of International
Medical Communications at Tokyo Medical University for their assis-
tance with the manuscript.
Disclosures
Conflicts of Interest: None declared.
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