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Nuclear Cardiology
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Nuclear Cardiology
Practical Applications
Fourth Edition
Gary V. Heller, MD, PhD, MASNC, FACC

Gagnon Cardiovascular Institute
Morristown Medical Center
Morristown, New Jersey
Robert C. Hendel, MD, MACC, MASNC, FAHA, FSCCT

Sidney W. and Marilyn S. Lassen Chair in Cardiovascular Medicine
Professor of Medicine and Radiology
Tulane University School of Medicine
New Orleans, Louisiana
New York Chicago San Francisco Athens London Madrid Mexico City

Milan New Delhi Singapore Sydney Toronto
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This edition is dedicated to the readers who will find this edition useful as this has been
the goal of our efforts to complete this revision, especially an era of COVID where
everything has been more difficult, but new important knowledge has been emerging and
important. I primarily dedicate this to my co-editor, friend and colleague, Bob Hendel,
who has had such an important role in all four editions bringing important comments,
revisions, and humor to the process.
G.V.H.
For my colleagues-past, present, and future, who have provided me with inspiration
throughout my career. Additionally, this book is also dedicated to those “behind the
scenes,” such as our dedicated and passionate technologists, thoughtful administrators, and
societal/regulatory personnel who help optimize the value of nuclear cardiology. And of
course, to Gary Heller, the instigator and inspirator for Nuclear Cardiology: Practical
Applications and kayaker extraordinaire.
R.C.H.
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CONTENTS
Contributors.. . . . . . . . . . . . . . . . . . . . . . . . . . . ix 9. SPECT Myocardial Perfusion

Imaging Protocols�� 141
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Milena J. Henzlova, Cole B. Hirschfeld
and Andrew J. Einstein
Section 1. F undamentals of 10. Cardiovascular Positron Emission
Nuclear Cardiology�� 1 Tomographic Imaging�� 155
1. Fundamentals of Nuclear Matthew J. Memmott, Parthiban Arumugam
and Gary V. Heller
Cardiology Physics�� 3
C. David Cooke, James R. Galt and 11. Myocardial Blood Flow Quantitation
E. Lindsey Tauxe in Clinical Practice�� 175
2. Radiation Safety and Protection in Krishna K. Patel, Gary V. Heller and
Timothy M. Bateman
Nuclear Cardiology�� 15
James R. Galt, C. David Cooke and Jason S. Tavel 12. Ventricular Function�� 195
Prem Soman and Saurabh Malhotra
3. Radiopharmaceuticals for
Cardiovascular Imaging�� 29 13. Non-Cardiac Findings�� 217
James A. Case and Gary V. Heller Rupa M. Sanghani and Jamario Skeete
4. Cardiac SPECT and PET Instrumentation�� 49 14. Interpretation and Reporting of SPECT
James A. Case and PET Myocardial Perfusion Imaging�� 233
Robert C. Hendel and Gary V. Heller
5. Quality Control in SPECT, Dedicated
PET, and Hybrid CT Imaging�� 73
Sue Miller, Sunil Selvin and Joey Stevens Section 3. Indications and Applications�� 271
6. Radiation Exposure and Reduction 15. Clinical Applications of Quantitation

Strategies in Myocardial Perfusion and Artificial Intelligence in Nuclear
Imaging�� 97 Cardiology�� 273
Michael C. Desiderio and Gary V. Heller Robert J.H. Miller and Piotr J. Slomka
7. Physician Certification and Laboratory 16. Appropriate Use of Nuclear Cardiology

Accreditation�� 109 Techniques�� 289
Robert C. Hendel and Gursukhman Deep S. Sidhu Gursukhman Deep S. Sidhu and
Robert C. Hendel
Section 2. R
adionuclide Myocardial 17. Evaluation of Patients with Suspected
Perfusion Imaging�� 119 Coronary Artery Disease�� 299
Sanjeev U. Nair and Gary V. Heller
8. Exercise and Pharmacologic
Stress Testing�� 121 18. Evaluation of Patients with
Seyed Mehdi Khalafi, Archana Ramireddy and Known Coronary Artery Disease�� 323
Robert C. Hendel Javier Gomez and Rami Doukky
vii
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viii Contents
19. Risk Stratification with Myocardial 24. Radionuclide Imaging of Cardiac

Perfusion Imaging�� 339 Innervation�� 457
Javier Gomez and Rami Doukky Mark I. Travin and Ana Valdivia
20. Nuclear Cardiovascular Imaging 25. Imaging Cardiac Amyloidosis�� 479

in Special Populations�� 371 Cory Henderson, Dillenia Rosica and
Robert C. Hendel, Michael C. Desiderio Sharmila Dorbala
and Gary V. Heller 18
26. F-FDG PET/CT for Imaging Cardiac
Sarcoidosis and Inflammation�� 495
21. Preoperative Risk Assessment for
Noncardiac Surgery�� 405 Cesia Gallegos, Bryan D. Young and
Edward J. Miller
Muhammad Siyab Panhwar, Sumeet S. Mitter
and Robert C. Hendel 27. Hybrid Imaging: SPECT–CT and PET–CT�� 517
Cory Henderson, Patrycja Galazka and
22. Radionuclide Imaging in Heart Failure�� 419 Sharmila Dorbala
Gautam V. Ramani and Prem Soman
Section 5. Review Questions�� 533
Section 4. Beyond Perfusion Imaging�� 429
Answers and Explanations for
23. Nuclear Cardiology Procedures in the Review Questions�� 563
Evaluation of Myocardial Viability�� 431
Christiane Wiefels, Fernanda Erthal, Benjamin Index�� 585
Chow, Gary V. Heller and Rob S.B. Beanlands
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CONTRIBUTORS
Parthiban Arumugam, MD Sharmila Dorbala, MD, MPH, FACC, MASNC

Consultant Nuclear Medicine Physician and Clinical Director of Nuclear Cardiology
Director Professor, Department of Radiology
Nuclear Medicine Centre Division of Nuclear Medicine and Molecular Imaging and
Manchester University NHS Foundation Trust the Noninvasive Cardiovascular Imaging Program
Manchester Royal Infirmary Heart and Vascular Center
Manchester, United Kingdom Departments of Radiology and Medicine (Cardiology)
Brigham and Women’s Hospital
Timothy M. Bateman, MD Harvard Medical School
Co-Director, Cardiovascular Radiologic Imaging Boston, Massachusetts
Saint-Lukes Health System
Professor of Medicine Rami Doukky, MD, MSc, MBA, FACC, FASNC
University of Missouri-Kansas City Professor of Medicine and Radiology
Kansas City, Missouri Chairman, Division of Cardiology
Cook County Health
Rob S.B. Beanlands, MD, FRCPC, FCCS, FACC, FASNC
Chicago, Illinois
Vered Chair and Head, Division of Cardiology
Professor, Medicine (Cardiology)/Radiology Andrew J. Einstein, MD, PhD, FACC, FAHA, MASNC,
Distinguished Research Chair University of Ottawa MSCCT, FSCMR
Director, National Cardiac PET Centre Associate Professor of Medicine (in Radiology)
University of Ottawa Heart Institute Director, Nuclear Cardiology, Cardiac CT, and Cardiac MRI
Ottawa, Ontario, Canada Director, Advanced Cardiac Imaging Fellowship
James A. Case, PhD, MASNC Seymour, Paul and Gloria Milstein Division of
University of Missouri, Columbia Cardiology, Department of Medicine, and Department
Chief Scientific Officer, Cardiovascular Imaging of Radiology
Technologies Columbia University Irving Medical Center/New York-
Kansas City, Missouri Presbyterian Hospital
New York, New York
Benjamin Chow, MD, FRCPC, FACC, FESC, FASNC,
MSCCT Fernanda Erthal, MD
Director of Cardiac Imaging Cardiac Imaging Staff
Saul & Edna Goldfarb Chair in Cardiac Imaging Department of Cardiac Imaging
Director of Cardiac Imaging Fellowship Training Diagnosticos da America SA (DASA)
Co-Director of Cardiac Radiology Rio de Janeiro, Brazil
Professor, Departments of Medicine (Cardiology) and Patrycja Galazka, MD
Radiology Fellow, Noninvasive Cardiovascular Imaging
University of Ottawa Heart Institute The Noninvasive Cardiovascular Imaging Program
Ottawa, Ontario, Canada Heart and Vascular Center
C. David Cooke, MSEE Departments of Radiology and Medicine (Cardiology)
Lead Applications Developer/Analyst Brigham and Women’s Hospital
Department of Radiology and Imaging Sciences Harvard Medical School
Emory University School of Medicine Boston, Massachusetts
Atlanta, Georgia
Cesia Gallegos, MD, MHS
Michael C. Desiderio, DO, FACC Assistant Professor of Medicine (Cardiology)
Medical Director, Cardiology Section of Cardiovascular Medicine
UPMC North Central Pennsylvania Region Yale University School of Medicine
Williamsport, Pennsylvania New Haven, Connecticut
ix
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x Contributors
James R. Galt, PhD Matthew J. Memmott, MSc

Director of Nuclear Medicine Physics Consultant Medical Physicist
Professor, Department of Radiology and Imaging Sciences Nuclear Medicine Centre
Emory University School of Medicine Manchester University NHS Foundation Trust
Atlanta, Georgia Manchester, United Kingdom
Javier Gomez, MD, FACC, FASNC Edward J. Miller, MD, PhD, FASNC, FACC
Assistant Professor of Medicine Associate Professor of Medicine (Cardiology) and
Director and Cardio-Oncology Services Radiology & Biomedical Imaging
Division of Cardiology Yale University School of Medicine
Cook County Health Section of Cardiovascular Medicine
Chicago, Illinois New Haven, Connecticut
Gary V. Heller, MD, PhD, FACC, MASNC Robert J.H. Miller, MD, FRCPC, FACC
Gagnon Cardiovascular Institute Clinical Assistant Professor
Morristown Medical Center Department of Cardiac Sciences
Morristown, New Jersey University of Calgary and Libin Cardiovascular Institute
Calgary, Alberta, Canada
Robert C. Hendel, MD, FAHA,
FSCCT, MACC, MASNC Sue Miller, CNMT
Sidney W. and Marilyn S. Lassen Chair in Cardiovascular Chief Operating Officer
Medicine Molecular Imaging Services, Inc.
Professor of Medicine and Radiology Newark, Delaware
Tulane University School of Medicine
New Orleans, Louisiana
Sumeet S. Mitter, MD, MSc
Assistant Professor
Cory Henderson, MD Department of Medicine, Division of Cardiology
Assistant Professor of Medicine and Radiology Icahn School of Medicine at Mount Sinai
Division of Cardiovascular Medicine, Department of New York, New York
Medicine
Boston University School of Medicine
Sanjeev U. Nair, MBBS, MD, FACP, FACC, FSCAI
Interventional Cardiologist
Boston, Massachusetts
SN Cardiovascular Associates
Milena J. Henzlova, MD Fort Worth, Texas
Professor of Medicine (retired)
Mount Sinai School of Medicine
Muhammad Siyab Panhwar, MD
Cardiovascular Medicine Fellow
New York, New York
Tulane University Medical Center
Cole B. Hirschfeld New Orleans, Louisiana
Fellow, Cardiovascular Disease
Weill Cornell Medicine
Krishna K. Patel, MD, MSc
Assistant Professor of Medicine (Cardiology) and
NewYork-Presbyterian Hospital
Population Health and Policy
New York, New York
The Zena and Michael A. Wiener Cardiovascular Institute
Seyed Mehdi Khalafi, MD Blavatnik Women’s Health Research Institute
Cardiovascular Medicine Fellow Institute for Transformative Clinical Trials
Tulane University Medical Center Icahn School of Medicine at Mount Sinai
New Orleans, Louisiana New York, New York
Saurabh Malhotra, MD, MPH, FACC, FASNC Gautam V. Ramani, MD

Director of Advanced Cardiac Imaging Associate Professor of Medicine
Cook County Health Division of Cardiovascular Medicine
Associate Professor of Medicine University of Maryland
Rush Medical College Baltimore, Maryland
Chicago, Illinois
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Contributors xi
Archana Ramireddy Joey Stevens, CNMT

Clinical Cardiac Electrophysiologist Senior Clinical Accounts Manager
Kaiser Permanente Northern California Molecular Imaging Services, Inc.
Santa Clara, California Newark, Delaware
Dillenia Rosica, MD E. Lindsey Tauxe, MEd, CNMT, FASNC

Clinical Assistant Professor of Radiology Operations Director (Retired)
Department of Radiology Medicine-Cardiovascular Disease
Geisinger Health System University of Alabama at Birmingham
Danville, Pennsylvania Birmingham, Alabama
Rupa M. Sanghani, MD, FACC, FASNC Jason S. Tavel, PhD, DABR

Associate Professor of Medicine Medical Physicist
Division of Cardiology Astarita Associates, Inc.
Rush University Medical Center Smithtown, New York
Chicago, Illinois Adjunct Assistant Professor
Molloy College
Sunil Selvin, CNMT Rockville Centre, New York
Vice President, Operations & Clinical Education
Molecular Imaging Service, Inc. Mark I. Travin, MD, FACC, MASNC
Newark, Delaware Department of Radiology/Division of Nuclear Medicine
Director of Cardiovascular Nuclear Medicine
Gursukhman Deep S. Sidhu, MD Montefiore Medical Center
Cardiologist Professor of Clinical Radiology and Clinical Medicine
Cardiovascular Institute of the South Albert Einstein College of Medicine
Lafayette, Louisiana Bronx, New York
Jamario Skeete, MD Ana Valdivia, MD
Cardiovascular Disease Fellow Department of Radiology/Division of Nuclear Medicine
Division of Cardiology, Department of Medicine Montefiore Medical Center
Rush University Medical Center Albert Einstein College of Medicine
Chicago, Illinois Bronx, New York
Piotr J. Slomka, PhD Christiane Wiefels, MD, MSc
Director of Innovations in Imaging, Cedars-Sinai Assistant Professor of Medicine
Professor of Medicine and Cardiology Division of Nuclear Medicine, Department of Medicine
Division of Artificial Intelligence in Medicine, University of Ottawa
Cedars-Sinai Ottawa, Ontario, Canada
Professor of Medicine, UCLA School of Medicine PhD Candidate
Los Angeles, California Federal Fluminense University
Prem Soman, MD, PhD Brazil
Professor of Medicine, and Clinical & Translational Bryan D. Young, MD PhD, FACC
Science Assistant Professor of Medicine
University of Pittsburgh Division of Cardiovascular Medicine, Department of
Associate Chief, Cardiology Internal Medicine
Director, Nuclear Cardiology and the Cardiac Imaging Yale School of Medicine; Yale New-Haven Health System
Fellowship New Haven, Connecticut
Director, Cardiac Amyloidosis Center
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
FM.indd 11 17-02-2022 12:14:09


PREFACE
We are pleased to present this fourth edition of Nuclear questions with detailed answers related to each chapter,
Cardiology: Practical Applications. We have undertaken found at the end of the book.
substantial revisions, emphasizing recent changes in tech- This fourth edition is ideally suited for trainees and
nology as well as the contemporary clinical applications of early-career professionals both radiologists and cardi-
nuclear cardiology. We have provided insight as to future ologists. Additionally, this book should be very useful for
directions of the field, delineating where this important technologists and healthcare professionals involved in
imaging modality is positioned in current-day clinical decision-making for testing procedures.
practice, especially in the setting of multi-modality imag- We are grateful to the contributors who have done an
ing. We have greatly expanded information regarding outstanding job updating and expanding the book and its
positron emission tomography, including an entire chapter value. We hope that you find the fourth edition of Nuclear
on the assessment of myocardial blood flow. Each chapter Cardiology: Practical Applications useful and that it will be a
now features a table of key points and many of the tables focal point for your nuclear cardiology education. To this end,
and figures have been updated and expanded. We believe it is our goal to assist in the improvement of nuclear cardiol-
these help in the learning process as well as providing easy ogy practice and to benefit the patients for which we care.
referencing key pieces of information. For your personal
knowledge assessment, especially for preparation for cre- Gary V. Heller
dentialing examinations, we have provided a multitude of Robert C. Hendel
xiii
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SECTION
1
FUNDAMENTALS OF
NUCLEAR CARDIOLOGY
sec01.indd 1 15-02-2022 12:34:58


Fundamentals of Nuclear CHAPTER
Cardiology Physics
C. David Cooke, James R. Galt and E. Lindsey Tauxe

1
structural character of the atom and nucleus. The
KEY POINTS ways in which radiation interacts with matter have a
direct relationship with imaging and radiation safety.
■■ Elements are defined by the number of pro-
The types of radiations and the ways in which they
tons in the nucleus. Nuclides are defined by
interact with matter are the foundation of radio-
the number of protons and the number of
nuclide imaging and radiation safety. This chapter
neutrons.
will focus on atomic and nuclear structure and the
■■ The ratio of protons to neutrons determines interaction of radiations with matter as they relate to
the stability of a nucleus. radionuclide imaging.
■■ Unstable nuclei decay to a more stable state
through several different mechanisms:
α decay, β− decay, β+ (positron) decay, elec- ATOMIC AND NUCLEAR STRUCTURE
tron capture, and isomeric transition.
Matter is composed of atoms and the character-
■■ The rate at which unstable nuclei decay can istics of a specific form of matter are determined
be described by the decay constant. It is by the number and type of atoms that make it up.
often more convenient to describe the rate How atoms combine is a function of their electron
of decay by the half-life. structure. The electron structure is determined by
■■ The interaction of radiation with matter is the nuclear architecture. As we have yet to image
dependent on the energy and type of the the atom, its structure is based on a “most-probable”
radiation, as well as the atomic number model that fits physical behaviors we observe. The
(Z number) of the matter. probabilistic approach is based on the model of
■■ Attenuation is the loss of radiation as it the atom proposed by Niels Bohr in 1913. The
passes through matter and is absorbed or Bohr atom proposed a positively charged nucleus,
deflected. surrounded by negatively charged electrons. A neu-
tral atom is one in which the positive and negative
charges are matched. A mismatch in these charges
INTRODUCTION determines the ionic character of the atom, which is
the basis for its chemistry. The electron configura-
A practical review of basic atomic and nuclear phys- tion is also a source for emissions used in radionu-
ics is essential to understand the origins of radia- clide imaging.
tions, as well as their interactions with matter. The These emissions, or radiations, will be in one
nature and type of emissions are determined by the of two forms: particulate or electromagnetic. The
ch01.indd 3 15-02-2022 09:36:29

4 Section 1 Fundamentals of Nuclear Cardiology
origins of either type of radiation may be from the n is the quantum number. Therefore, the maximum
nucleus or the electron structure. number of electrons for each shell is:
▶▶Electron Configuration K = quantum #1 = 2(1)2 = 2 electrons

L = quantum #2 = 2(2)2 = 8 electrons
Electrons are arranged around the nucleus in M = quantum #3 = 2(3)2 = 18 electrons
shells. The number of shells is determined by the These shells are further subdivided into substates.
number of electrons, which is, in turn, determined The number of substates for each shell can be calcu-
by the number of protons in the nucleus. The force lated by 2n − 1; therefore:
exerted on these shells, called binding energy, is
determined by the proximity of the shell to the K shell = 2(1) − 1 = 1 substate
nucleus. Higher binding energies are exerted on L shell = 2(2) − 1 = 3 substates
shells closest to the nucleus and conversely, lower M shell = 2(3) − 1 = 5 substates
binding energies for those more distant from the
nucleus. The innermost shell is named the “K” shell Each substate for a given shell will have a unique
and electrons in this shell are subject to the high- binding energy. For instance, the L shell has three
est binding energy. The magnitude of that energy substates, LI, LII, and LIII.1 Each of these has slightly
is dependent on the positive forces, which is deter- different distances from the nucleus, and therefore
mined by the number of protons in the nucleus. slightly different binding energies (Fig. 1-2).2
The shells more distant from the nucleus are named
Atomic Radiations
L, M, N, and so on. Each of these shells has lower
binding energies as a result of their distance from Electrons in inner shells being under high binding
the nucleus (Fig. 1-1). energy and thus tightly bound to the nucleus are in
The radii of each of these shells increase as a an inherently low-energy state. Outer shell and free
function of their distance from the nucleus. An
electrons are in an inherently higher-energy state.
expression of this is given by assigning an integer Therefore, to move an inner shell electron to an outer
value (1, 2, 3, …) to each shell. The lower values rep- shell requires energy. The amount of energy required
resent smaller radii. These integer values are called is simply the difference between binding energies.
quantum numbers. Therefore, the K shell has a quan- Example: Binding energy for a hypothetical “K”
tum number of 1, L = 2, M = 3, etc. This pattern shell = 100 keV and “L” = 50 keV. K100 − L50 = 50 keV
continues until all available electrons are bound to a
shell. The innermost shells are filled with electrons
preferentially. The maximum number of electrons is
specific to each shell and is calculated by 2n2, where
L shell
K shell
LI substate
LII substate
K shell LIII substate
• High binding energy
L shell
• Low binding energy
M shell
• Lower binding energy Unique binding energies
LIII>LII>LI
FIGURE 1-1 Atomic structure. The nucleus is surrounded by FIGURE 1-2 Electron configuration. Electrons are arranged
electron shells. The binding energy decreases as the distance in subshells, as illustrated for the L shell. Each subshell has a
from the nucleus increases (K > L > M). unique binding energy.
ch01.indd 4 15-02-2022 09:36:32

Chapter 1 Fundamentals of Nuclear Cardiology Physics 5
of energy input to move the electron from the “K” Z (Atomic number) = # Protons
shell to the “L” shell. N = # Neutrons
Conversely, the movement of an electron from an
outer shell to an inner shell, L → K, yields energy. Since the number of neutrons (N) can be derived
This energy yield results in the emission of radiation. from the atomic mass number (A) and the number
The energy of the radiation is equal to the differences of protons (Z), it is usually omitted (N = A − Z). In
in binding energies of the shells. The radiation may addition, since the number of protons (Z) defines an
take on two different forms: characteristic x-ray or element, as does its chemical symbol (X), only one is
Auger (oh-zhay) effect. necessary; hence, Z is often omitted as well.
Example: Binding energy for a hypothetical “K” The total mass of an atom is essentially the com-
shell = 100 keV and “L” = 50 keV. K100 − L50 = bined masses of the nucleons. Electrons contribute
50 keV of energy released as the electron moves from less than 1% to the total mass.1
the “L” shell to the “K” shell. Nuclides having the same number of protons (Z)
Characteristic x-rays are electromagnetic radiations are called isotopes. Isotopes are the same element, but
(photons) that are created when an outer shell electron have different atomic masses (A) and therefore have
moves to fill an inner shell vacancy. This vacancy may different numbers of neutrons (N); for example: 125 53I72 ,
127 131
occur for several reasons—to be discussed later. The I
53 74 , and I
53 78 . Nuclides with the same number of
energy of this photon is equal to the difference between neutrons (N) are called isotones and will be differ-
binding energies. Since binding energies are deter- ent elements, since the number of protons (Z) will
132
mined by, or characteristic of, the number of protons in be different; for example: 131 133
53I78 , 54 Xe78 , and 55Cs 78.
the nucleus, and it is the number of protons that deter- Nuclides with the same atomic mass number (A)
mines an element’s identity, the characteristic x-ray are called isobars and are different elements as well,
energies are specific to each element and the electron since they will have different numbers of protons (Z)
99
shells from which they originate. X-radiation is defined and neutrons (N); for example: 99 42 Mo57 and 43Tc56.
as an electromagnetic radiation originating outside the Finally, nuclides with the same number of protons
nucleus, therefore the term characteristic x-ray. (Z) and neutrons (N), but in different energy states
The Auger effect occurs under the same condi- are called isomers; for example: 99m 99
43Tc and 43Tc. An
tions as characteristic x-ray, that is, an inner shell easy mnemonic for remembering this is that isotopes
vacancy being filled by an outer shell electron. The (with a p) have the same number of protons, isotones
difference is that the excess energy from the cas- (with an n) have the same number of neutrons, iso-
cading electron is radiated to another electron. This bars (with an a) have the same atomic number, and
ejects that electron from its shell. This free electron isomers (with an e) are the same nuclide with differ-
will have kinetic energy equal to the difference in the ent energies.
binding energies less the binding energy of the shell Isotopes having different N numbers are of par-
of the free electron. The Auger effect is more com- ticular interest to imagers because they have the same
mon in elements with lower numbers of protons chemistry, since their Z numbers and, therefore, elec-
(Z number).1–3 tron numbers are the same.1–5 Some isotopes exhibit
the emission of radiations, which is due to the dif-
▶▶Nuclear Structure ferences in the number of neutrons. These isotopes
are called unstable. If all the stable isotopes of all
The nucleus is composed mainly of neutrons and elements are plotted, comparing proton number to
protons. Any particle contributing to the structure neutron number, a pattern emerges as illustrated in
of the nucleus is called a nucleon. The conventional Figure 1-3.
nomenclature to describe the nucleons is: AZ X N . Elements with low Z numbers have proton to
neutron ratios that are 1:1. As Z numbers increase,
where:
this ratio increases to as high as 1.5. This distribu-
X = Symbol of the chemical element tion of stable elements is called the line of stability.
A (Atomic mass number) = Total number of nucle By definition, an element with a proton to neutron
ons = # Protons + # Neutrons ratio that falls to either the left or right of the line of
ch01.indd 5 15-02-2022 09:37:29

Line of stability and dosimetry perspectives, due to their lower prob-

ability of creating potentially damaging interactions
100 as compared to particles. With these considerations,
it is important to understand the modes of decay
80 Neutron-rich of 99mTechnetium, 201Thallium, and 82Rubidium—
zone the most commonly used radionuclides in nuclear
Neutron number (N)
60
cardiology.1,2
Z
=
40
N β− Decay
Proton-rich
zone In an unstable nuclear configuration where the
20 nucleus is neutron rich, β− decay occurs. To decrease
the neutron–proton ratio, a neutron is converted to
0 a proton and an energized electron is emitted. The
0 20 40 60 80 100 expression of this nuclear transition is:
Atomic number (Z)
FIGURE 1-3 Line of stability. All naturally occurring stable n → p + e− + ν + energy
nuclides fall along a distribution known as the line of stability
(LOS). As illustrated, for light elements (Z < 20) N ~ Z and for
heavier elements N ~ 1.5Z. Unstable elements, lying to the left where n is the neutron, p the proton, e the electron,
of the LOS, are neutron rich; those lying to the right of the LOS and ν is the neutrino.
are proton rich. The neutrino (ν) behaves like a particle with no
mass and is not critical to imaging considerations.
The primary emission is the energized electron (e−).
stability is unstable. The unstable isotopes, radioiso- The nuclear configuration that results from β− decay
topes, are unstable because their nuclear configura- is a daughter with a stable or more stable energy state
tions are either proton rich or neutron rich relative and an additional proton in its nucleus.
to stable configurations. These radioactive elements Example: 146C 8 → 147 N7
seek stability by undergoing transformations in their
nuclear configurations to a more stable P ↔ N ratio. Since the number of protons is changed, the ele-
The type of transformation will be a result of the mental identity changes. This is called a transmuta-
P ↔ N ratio, that is, proton rich versus neutron rich. tion. The daughter atomic mass (A) remains the same
This type of transition is called the mode of decay.1–4 as the parent nucleus, and the energy carried off by
the ejected electron is called transition energy. This
Modes of Decay leads to a more balanced relationship of coulom-
bic force (repelling forces due to the protons) and
The goal of nuclear decay is to equate the balance of exchange force (attractive nuclear forces). The result-
forces in the nucleus. The repelling forces originating emission of the energized electron, a β− particle,
ing from the positive charge (coulombic forces) of the is of no use in imaging and contributes to an increase
protons, when matched by the attractive forces from in radiation dose in a biologic system. This decay pro-
within the nucleus (exchange forces), define stability. cess may lead to a daughter that is not fully stable, but
When these forces are mismatched, nuclear trans- more stable than the parent.1,2 The change in nuclear
formations (radioactive decay) result. The mode of configuration is an increase in Z and a decrease in N.
decay will produce unique emissions and lead to a
more stable nuclear configuration. In radionuclide β+ Decay
imaging, the ideal mode of decay would result in a
high yield of photons, at an energy that is efficiently In nuclear configurations where the parent is proton
detected by our imaging instrumentation. Photon rich, β+ decay may occur. In this mode of decay, a
emission is also desirable from the radiation safety proton is converted to a neutron and the emission of
ch01.indd 6 15-02-2022 09:37:33

an energized, positively charged electron (β+) results. daughter, since the nuclear transition occurred prior
The nuclear equation is: to the production of the x-rays and Auger electrons.
It is the characteristic x-rays that are imaged in 201Tl
p → n + e+ + ν + energy myocardial perfusion imaging. The energy of the
x-rays is determined by the binding energy of 201Hg,
The energy of the β+ particle contributes to the daughter of the decay of 201Tl. Electron capture
resolving the transition energy between the unstable decreases the proton–neutron ratio.1
parent and more stable daughter, as in β− decay.
Example: 20181Tl120 → 201
80 Hg121
An important secondary emission will result
from the formation of the β+ particle. Since there
is an abundance of negatively charged electrons in Isomeric Transitions and Internal Conversions
nature, the resulting positively charged electron (β+)
will be attracted to, and collide with, a free negatively The daughter of the decay of a radioactive parent
charged electron. This collision results in the anni- will ideally be in its most stable energy configuration
hilation of both particles. The annihilation leads to or ground state. This does not always occur, leading
the conversion of the mass of these particles to their to either of the two unstable states: excited state or
equivalent energy state. This is expressed by Einstein’s metastable state. Excited states are very unstable and
equation E = mc 2, where E is energy, m the mass, exist for very short time periods, usually less than
and c is the speed of light. This essentially states that 10−12 seconds. Metastable states, however, may exist
energy and mass are simply two physical forms of the for several hours. These metastable states lead to
same thing. Therefore, two photons (E) are emitted, the release of energy in the form of electromagnetic
each with the energy equivalent to the mass (m) of an emissions, without changing the proton–neutron
electron, which is 511 keV. Unique to this annihila- ratios. The daughter nucleus has the same nuclear
tion is that these photons are emitted in a 180-degree structure as the parent has, but in a more stable
trajectory from each other. It is these photons that energy configuration. This form of decay is called
are detected and registered into an image in positron an isomeric transition and results in electromagnetic
imaging, such as with 82Rb. The change in nuclear emissions called γ-rays. These emissions are the same
configuration is a decrease in Z and an increase in N. as x-rays, differing only by their location of origin,
82 82 that is, the nucleus. As noted with the production of
Example: 37 Rb45 → 36 Kr46
characteristic x-rays, there is a competing process,
resulting in a particulate radiation. This process is
Electron Capture called internal conversion. For any given metastable
state, there is a specific ratio of isomeric transitions to
An alternative to β+ decay in proton-rich nuclear internal conversions. In imaging, the higher percent-
configuration is electron capture. This mode of decay age of isomeric transitions compared to internal con-
is defined as the capture of a K-shell electron by the versions is preferred due to the resulting higher yield
nucleus, the subsequent combination with a proton, of photons. The decay of 99mTc to 99Tc is an example of
and creation of a neutron. The nuclear expression is an isomeric transition of the metastable state (99mTc).
therefore: The percent occurrence of isomeric transitions of a
population of 99mTc nuclei is approximately 87%. For
p + e- → n + ν + energy example, for every 100 decays of 99mTc nuclei, there
is a yield of 87 γ-photons and 13 internal conversion
The vacancy left by the captured electron would electrons.
then be filled by an outer shell electron. A cascade For any given mode of decay, should the daughter
of an electron, filling subsequent vacancies, cre- be metastable, there will be the emission of γ-photons
ates secondary emissions called characteristic x-rays and internal conversion electrons as secondary emis-
and Auger electrons. The energies of these emissions sions. This will be indicated as [B−, γ], [B+, γ], [EC,
will be characteristic of the binding energy of the γ], and so forth. The internal conversion electron
ch01.indd 7 15-02-2022 09:37:41

yield, in ratio to γ-photon yield, is specific to a given

A P = Parent
radionuclide.1,2,5 D = Daughter
P
Z
Alpha (α) Decay Alpha
A−4 β− A
D1 mD4
In unstable nuclei with very high atomic masses, the Z+1
Energy
Z−2 β+
most probable mode of decay is α decay. An alpha
A
particle consists of two protons and two neurons, D2 EC IT
A
which is essentially a helium nucleus. Alpha decay Z−1 (electron D4 (isomeric
results in a daughter with a Z number of 2 less than A capture) Z + 1 transition)
the parent and an atomic mass less by 4 relative to D3
Z−1
the parent.
Example: 235
92 U143 →
231
90Th141 Z−2 Z−1 Z Z+1
Atomic number
Due to its high charges and heavy mass, the alpha
FIGURE 1-4 Decay schemes. This figure illustrates the
particle has a very short travel distance in matter and configurations of decay schemes for the different modes
deposits its energy very quickly. It has no application of decay. The schemes move to the left for proton-rich
in diagnostic imaging and induces significant poten- radionuclides and to the right for neutron-rich radionuclides.
tial for biologic damage.1,3
Decay Schemes
Parent–Daughter Equilibrium
The modes of decay may be expressed graphically,
called decay schemes. Decay schemes graphically Not all nuclear transitions lead to a stable daughter.
illustrate all possible nuclear transitions that unstable The β− decay of 99Mo yields 99mTc, which then decays
nuclei undergo. They are often accompanied by tables to 99Tc by isomeric transitions and internal conversions.
99m
with detailed information about the transitions, such Tc decays to 99Tc with an 87% frequency through
as the percentage occurrence, isomeric transitions, isomeric transitions. Therefore, for every 100 decays
internal conversions, characteristic x-rays, Auger of 99mTc, we observe 87 γ-rays and 13 internal con-
electrons, and biologic dose information. version electrons, as stated earlier. This higher yield
In decay schemes, the nuclear energy levels are of photons makes 99mTc a very desirable radionuclide
expressed as horizontal lines. The space between for imaging. A sample of 99Mo would always contain
these lines represents the transition energy (Q). some proportion of 99mTc and 99Tc. Since both par-
The types of emissions are depicted by a unique ent and daughter are decaying, the relative activities
direction of a line (Fig. 1-4). would reach equilibrium, based on their half-lives.
Note that the arrows may be angled to either These states of equilibrium are employed when using
the right or left. In neutron-rich parents, the mode both technetium and rubidium generators. When
of decay “shifts” the daughter to the right, corre- the parent half-life is marginally longer than that
sponding to the shift on to the line of stability graph. of the daughter, the amount of the daughter in the
Conversely, a mode of decay for a proton-rich parent mixture will reach a maximum over a period of time.
moves to the left, toward the line of stability. That elapsed time will be a multiple of half-lives of
The tables that accompany decay schemes provide the daughter. If the daughter radionuclide is removed
additional detail including the secondary emissions, from the mixture, the same multiple of half-lives will
as mentioned earlier. Since many of the secondary have to occur, before the maximum amount of the
emissions are particulate, that is, electrons, these daughter is subsequently reached. This equilibrium
data are of particular interest in radiation dosimetry. state is called transient equilibrium.2,4 It is this tran-
In the decay scheme for 201Tl, the data regarding the sient state that is the basis of 99mTc production from
99
characteristic x-rays of 201Hg are in these tables. Mo–99mTc generators (Fig. 1-5).
ch01.indd 8 15-02-2022 09:37:46

Parent
Parent
Daughter
Activity
Activity
Daughter
1 2 3 4 Time
1 2 3 4 Time 7 8 9 10
(Number of daughter half-lives)
(Number of daughter half-lives)
FIGURE 1-5 Transient equilibrium. When the parent half-life FIGURE 1-6 Secular equilibrium. When the parent half-life
is marginally longer than that of the daughter, the amount of is considerably longer than that of the daughter, the amount
daughter activity will reach a maximum after relatively few of parent activity will decrease very little over time. Therefore,
daughter half-lives have passed. 99Mo and 99mTc typically reach many more daughter half-lives must pass before the equilibrium
transient equilibrium after approximately four 99mTc half-lives. is reached. An example is 82Sr with a half-life of 25 days and
82
Rb with a 1.2-minute half-life.
In parent–daughter mixtures where the half- radioactive nuclei and λ the decay constant. Since the
life of the parent is markedly longer than that of the total N decreases with time (t), the decay constant (λ)
daughter, secular equilibrium is reached. In this state is a negative value.1,2,4 The number of transitions per
of equilibrium, the concentration of the parent is unit time (∆N/∆t) is called activity. Activity is mea-
decreasing so slowly relative to the daughter that the sured in curies (Ci), which is defined as 3.7 × 1010
mixture appears to have the half-life of the parent. It disintegrations per second (dps). The International
is this equilibrium that is the basis for the 82Sr–82Rb System of Units (SI) unit equivalent is the bec-
generators used in 82Rb positron emission tomogra- querel (Bq), which is defined as 1 Bq = 1 dps. So
phy (PET) imaging (Fig. 1-6).1 1 Ci = 3.7 × 1010 Bq. The most commonly used units
are in the mCi (MBq) range for nuclear cardiology
RADIOACTIVITY procedures.
In nuclear decay, the number of radioactive
The specific time that an unstable nucleus will nuclei (N) is always decreasing as time passes at an
undergo a transition cannot be determined, only average rate defined by the decay constant (λ). Decay
predicted. Nuclear transitions are spontaneous and is expressed, therefore, as an exponential function;
random, so the mathematics of radioactive decay is that is, the number of radioactive nuclei available is
based on probabilities and rates, not specific nuclear affected by both the number of unstable nuclei and its
events. If a population of radioactive atoms, N, is average rate of decay. To calculate the specific num-
considered, the rate of nuclear transitions would be ber of decays for a given time, we have the following
expressed as ∆N/∆t. The rate implies that a constant expression:
would express the average number of transitions that
occur per unit time. This constant is called the decay N (t) = N (0) e−λt
constant; which is specific to a given radionuclide
and is expressed as λ. The mathematical relationship where N(t) is the number of unstable nuclei remaining
is: ∆N/∆t = −λN, where N is the total number of after the elapsed time (t) has passed. The expression
ch01.indd 9 15-02-2022 09:37:56

e−λt is called the decay factor (DF) and is unique to the the past, the precalibrated value. In this case, the DF
time (t) and the decay constant (λ). The “e” is the base would be the reciprocal of the elapsed time DF1,2:
of natural logs, which is 2.718, so, when raised to the
power of −λt, it determines the specific fraction of 1
DF =
remaining radioactive nuclei after time (t) has elapsed. 0.817
When the elapsed time (t) is the time required DF = 1.22
for half of the total number of radioactive nuclei to
decay, it is termed the half-life. Half-life (T1/2) and the So, we have:
decay constant (λ) are related as:
A(0) = (24.51)(1.22) = 30 mCi
ln 2
T1/2 =
λ
Since ln 2 is equal to 0.693, we have: INTERACTIONS OF RADIATION

WITH MATTER
0.693
T1/2 = As discussed earlier, there are distinct types of
λ
radiations: particulate and electromagnetic. These
radiations have distinct interactions with matter.
The activity (Ci) is dependent on the number of Interactions of radiations with matter are processes
unstable nuclei and the decay constant. Therefore, that absorb or degrade the energy of the radiation
units of activity (A) can be substituted for the num- and, in some cases, change its fundamental charac-
ber of radioactive nuclei (N), in the decay equation, teristics. The energy of the radiation and the Z num-
yielding the following expression: ber of the matter determine the type of interaction
or multiple interactions that occur. Depending on
A(t) = A(0) e−λt the energy, radiations may be nonionizing; that is, the
energy is not sufficient to free electrons from their
orbit. If the energy is sufficient to free electrons from
where A(t) is the activity at elapsed time t, A(0) the
their binding energy, the radiation is ionizing. The
activity at t = 0, and e−λt is the decay factor for the
energy of the ultrasound radiations in echocardiog-
specific time (t).
raphy does not cause ionization in tissues, and thus
As an example of practical use, consider a
is labeled “nonionizing.” The photons used in cardiac
30-mCi syringe of a 99mTc-labeled myocardial per-
catheterization and nuclear cardiology are classified
fusion agent. The calibration time for the 30 mCi is
as ionizing, implying that their interaction with tis-
8:00 am. What will be the activity at 9:45 am?
sue creates ion pairs. This interaction in tissue forms
the basis for radiation biology as applied in radiation
A(0) = 30 mCi
safety practices. Further, these interactions form the
A(t) = ? physical bases for detecting radiation and creating
t = 1 h, 45 min or 1.75 h images in our instrumentation.
0.693 0.693
λ= = = 0.1155
T1/2 6h ▶▶Particle Interactions with Matter
A(t) = 30 e−(0.1155)(1.75)
As we have stated, radionuclide images are created
A(t) = 30 × 0.817 through the detection of photons and γ-rays for
A(t) = 24.51 mCi 99m
Tc, characteristic x-rays for 201Tl, and annihilation
photons for 82Rb and other PET radiopharmaceuti-
The same principles apply in the situation where cals. When photons undergo interactions in matter,
an activity determination is required for a time (t) in either tissue or imaging detectors, energized charged
ch01.indd 10 15-02-2022 09:38:38

particles that are electrons, are produced. Particles, and mass, will lose its energy over a longer path
either β or α, interact with matter through electri- length, and is thus characterized as a low LET par-
cal collisions. These collisions result in excitation, ticle. The LET may also be expressed in terms of the
ionization, or bremsstrahlung. In excitation, energy relative number of ionizations that is produced. This
from the incident particle is transferred to an outer is termed specific ionization. Particles with a high LET
shell electron. The electron is energized but does not have high SI values; particles with a low LET have low
exceed its binding energy. That increased energy is SI values. LET and SI characteristics have profound
dissipated generally as heat radiation. Excitation is a impact on the type of damage done to tissue.
low-energy interaction.
A higher-energy interaction occurs when the ▶▶Photon Interactions with Matter
incident particle transfers enough energy to exceed
the binding energy of the electron. An ion pair, an The interactions of photons in matter are energy-
energized free electron and a positive ion, results. degrading processes, just as in particle interactions.
These ionizing interactions represent higher-energy There are three mechanisms of photon interaction
level interactions and contribute to the specific expo- in matter: photoelectric absorption, Compton scatter,
sure rate when applied to tissue, discussed in detail and pair production. The probability of occurrence
in a later chapter. for each of these mechanisms is a function of the
The third type of particulate interaction results energy of the photon and the atomic number of the
when the incident particle penetrates the electron matter (Fig. 1-7).
cloud and interacts with the charge field of the Photoelectric absorption occurs when the photon
nucleus. The trajectory of the incident particle is transfers all of its energy to an inner shell electron.
markedly changed, resulting in a decrease in veloc- The photon is completely absorbed and the electron,
ity. The decrease in velocity represents an energy loss. called a photoelectron, is ejected from its shell. The
That energy loss produces photons of x-rays called energy of the photoelectron is equal to the incident
bremsstrahlung, German for breaking radiation. photon energy, minus the binding energy of its shell.
Bremsstrahlung interactions are high-energy inter- It is key to remember that the photon no longer exists
actions more typical of high-energy particles inter- (it has been absorbed) and its energy is converted
acting with high Z number matter.
Since any of these interactions may lead to par- 100
tial dissipation of the energy of the incident particle,
multiple interactions are required for the full energy
of the particle to be absorbed in matter. These multi- Photoelectric Pair
75
ple interactions occur along a path that is determined absorption production
by the energy, charge, and mass of the particle, as well
Atomic number
as the Z number of the matter. A highly charged mas-

sive particle will undergo many high-energy inter- 50
actions over a very short path length. Alternately, a
lower-energy, less massive particle will undergo sev-
eral low-energy interactions over a long path length. 25
The difference in the degree of penetrability of the
Compton
particle is called linear energy transfer (LET). A heavy Tissue Tl & Tc scatter
highly charged particle would have a high LET, since
the density of interactions is high over a short path 0
0 0.1 1.0 10.0 100.0
length. An alpha particle because of its high charge Photon energy (MeV)
(two protons) and heavy mass (Z = 2; A = 4) has
FIGURE 1-7 Probability of interaction. The probability of the
a high LET where dense levels of excitation, ioniza- interaction of a photon in matter as a function of photon energy
tion, and bremsstrahlung are created in a very short and Z number is illustrated. Note the most probable interaction
distance. In contrast, a β particle, having little charge of photon from either 99mTc or 201Tl, in tissue, is Compton scatter.
ch01.indd 11 15-02-2022 09:38:38

from electromagnetic energy to kinetic energy of the medium-energy photons, interacting in matter with
photoelectron. The kinetic energy of the photoelec- low atomic masses. This is of particular interest in
tron is dissipated by the mechanisms previously dis- imaging, since it is the most probable interaction of
201
cussed: excitation, ionization, and bremsstrahlung. Tl (Hg x-rays) and 99mTc γ-rays in tissues. As the
The vacancy left by the ejected electron is quickly photons are scattered, not absorbed, they still exist,
filled by an outer shell electron. Characteristic x-rays but have lost their association with the point of origin
and Auger electrons are then emitted, as described through the scattering process. These photons are the
earlier. Photoelectric absorption is most probable source of image degradation, but can be identified by
in interactions of low- to medium-energy photons their lower-energy values. The identification of these
in matter with high atomic numbers. Photoelectric photons and their rejection from an image are critical
absorption is what makes gamma camera photo- functions of imaging equipment.1–5
multiplier tubes (PMTs) possible. The third interaction of photons in matter is pair
The second mode of interaction is Compton scat- production. High-energy photons may completely
ter. It occurs when a photon interacts with an outer avoid interacting with orbital electrons and interact
shell electron, that is, an electron with low binding in the magnetic field of the nucleus. This interaction
energy. Contrary to photoelectric absorption, the results in the creation of a pair of electrons, one posi-
photon is not completely absorbed. It transfers a tive and one negative. The positive electron imme-
portion of its energy to the electron, which is subse- diately combines with a negative electron, creating
quently ejected, and called a Compton electron. The two 511-keV annihilation photons. The energy of
resultant Compton scattered photon is in an energy- the incident photon must be at least two times the
degraded state and in an altered trajectory relative mass energy equivalency of an electron (511 keV) or
to the incident photon. The angle of the scattered 1.022 MeV. Since energies in this range are not used
photon is related to the amount of energy transferred in imaging, pair production is not relevant to this
to the electron. The greater the amount of energy discussion.2
transferred to the electron, the greater the angle of These three mechanisms are illustrated in
scatter. Compton scatter is most probable in low- to Figure 1-8.
γ Photon
Compton electron
γ Photon γ Photon
Photoelectron
Annihilation photon
e+
e–
Annihilation photon
A B C
FIGURE 1-8 (A) Photoelectric absorption. All photon energy is transferred to the ejected photoelectron. (B) Compton scatter. Partial
energy transfer, incident photon scattered by angle θ. (C) Pair production. Photon converts to an electron pair (β−, β+); annihilation
photon results.
ch01.indd 12 15-02-2022 09:38:39

Table 1-1
Half-Value Thickness for Tl, Tc, and Rb
Half-Value Thickness (mm)
201 99m 82
Matter Z Number Tl (80 keV) Tc (140 keV) Rb (511 keV)
Pb 82 0.25 0.30 3.80
Tissue (H2O) 8 38.0 46.0 73.0
Nal 53 0.67 2.40 21.0
▶▶Attenuation thickness (HVT) or half-value layer (HVL). The

HVT can be calculated by:
These interactive processes, in addition to photon
energy and atomic number, are affected by the thick- 0.693
HVT =
ness of the absorber. For a given thickness, a number µ
of photons will not interact and therefore be trans-
mitted. As the thickness of the absorber increases,
where µ is the linear attenuation coefficient and
the fraction of transmitted photons will decrease. The
0.693 is the ln 2. Note that this is the same equation
fraction of absorbed photons is a function of photon
as used in calculating the half-life of a radionuclide.
energy and atomic number, but the total number of
The absorption characteristics of tissue are essentially
photons absorbed is a function of the thickness of
the same as those of water, since the linear attenua-
the absorber.1 For any given relationship of photon
tion values are similar. Table 1-1 illustrates the differ-
energy and atomic number, there is an average rate
ences in HVTs for lead, a common material used in
of absorption. The rate is called the linear attenua-
shielding, water (tissue), and NaI, a common detec-
tion coefficient and is symbolized by µ. Since the lin-
tor material in imaging equipment.
ear attenuation coefficient is a fixed rate, the rate of
Note that the HVTs in tissue for 201Tl (80 keV)
transmitted photons is also fixed. If the thickness of
and 99mTc (140 keV) are 38.0 and 46.0 mm, respec-
a given absorber is doubled, those transmitted pho-
tively. It is typical to have these thicknesses of tissue
tons will be subject to further absorption. The math-
overlaying the heart. If these thicknesses reduce the
ematical relationship of incident beam intensity,
beam intensity by 50%, the imaging effects would be a
transmitted beam intensity, and linear attenuation is
reduction in count density of 50%, as well. Also note
exponential.
that 511 keV annihilation photons (from PET) are
The mathematical expression is:
attenuated less than either 201Tl or 99mTc (because of
the higher energy); however, since both photons must
I(x) = I(0) e−µx be detected for the event to be counted, the effects of
attenuation on PET images may be more pronounced.
where I(x) is the beam intensity after interacting with It is critical, therefore, to differentiate these tissue atten-
an absorber of thickness x and a linear attenuation uation effects, from reductions in biodistributions of
coefficient of µ, from an initial intensity I(0).6 This tracers when interpreting radionuclide images.
mathematical expression is the same as used in pre-
dicting the reduction in activity over time. Therefore, CONCLUSION
the expression e−µx is the specific fraction of absorbed
photons by a specific thickness of matter. The thick- In summary, the photons we use to construct cardiac
ness of a given absorber that results in a reduction of radionuclide images come from both nuclear and
initial beam intensity of 50% is called the half-value atomic sources, as demonstrated by the emissions
ch01.indd 13 15-02-2022 09:38:52

from 99mTc and 201Tl, respectively. The emissions used REFERENCES

may also be the result of processes that are secondary
to the primary emission, as seen with the annihila- 1. Cherry SR, Sorenson JA, Phelps ME. Physics in Nuclear Medi-
tion photons from the decay of 82Rb. The principles cine. 4th ed. Philadelphia, PA: Saunders/Elsevier Science;
2012:7–18, 19–30, 31–42.
of the detectors used in imaging equipment, as well 2. Chandra R, Rahmim A. Nuclear Medicine Physics: The Basics.
as those used in radiation safety, are based on the 8th ed. Philadelphia, PA: Wolters Kluwer; 2018:1–8, 9–20,
characteristics of photons and the matter in which 21–32.
they interact. Those characteristics are defined by the 3. Cook SE. Moderate Atomic and Nuclear Physics. Princeton, NJ:
D. Van Nostrand Company, Inc.; 1961.
physics of nuclear structure, mass–energy relation- 4. Murphy PH, Galt JR. Radiation physics and radiation safety.
ships, and radiation interactions in matter. In: Iskandrian AE, Garcia EV, eds. Nuclear Cardiac Imaging.
As a practical consideration, it is important to 5th ed. New York, NY: Oxford University Press; 2016:11–35.
5. Jelley NA. Fundamentals of Nuclear Physics. Cambridge,
note that radionuclide image quality is directly related
United Kingdom: Cambridge University Press; 1990:26–31,
to the type, energy, and the behavior in matter of 140–158.
photons. The three mainstream radionuclides used in 6. Saha GB. Basics of Pet Imaging. New York: Springer Science +
nuclear cardiology, 99mTc, 201Tl, and 82Rb, exhibit all of Business Media; 2005:1–14, 111–121.
these physical differences; therefore, familiarity with
the physical basis of radiation physics is essential.
ch01.indd 14 15-02-2022 09:38:52

Radiation Safety and CHAPTER
Protection in Nuclear
Cardiology
James R. Galt, C. David Cooke and Jason S. Tavel
2
KEY POINTS INTRODUCTION
■■ Important concepts used to describe radia- The Health Physics Society defines radiation as
tion include exposure, absorbed dose, and “energy that comes from a source and travels through
dose equivalent. space.”1 Radiation can be atomic particles such as
alpha and beta emissions, as well as electromagnetic
■■ A relatable way of explaining the radiation
energy associated with radio, microwaves, radar, vis-
dose from medical procedures to patients is
ible light, ultraviolet light, x-rays, and gamma rays. If
to compare the dose to the reference dose,
the radiation has enough energy to remove an elec-
the yearly radiation exposure from natural
tron from an atom, creating an ion, it is termed ion-
sources.
izing radiation.2 Ionizing radiation includes x-rays,
■■ Institutions must maintain radiation levels gamma rays, and alpha and beta particles and can
consistent with the As Low As Reasonably lead to biological damage by depositing energy in
Achievable (ALARA) philosophy. living tissue, breaking molecular bonds.
■■ Deleterious effects of radiation are classi- This chapter will introduce units that describe
fied as either stochastic, where the prob- radiation, sources of radiation exposure, radiation
ability of occurrence increases with dose, dose limits and introduce radiation biology. The
or deterministic, in which the severity chapter will further focus on radiation safety and
increases with dose after a threshold is protection regulations pertinent to the practice of
exceeded. nuclear cardiology. In the United States of America
■■ Major factors in limiting dose are time, dis- (USA), these regulations are governed by the Nuclear
tance, and shielding. Regulatory Commission (NRC) and are found in
■■ Regulatory agencies, such as the Nuclear Title 10, Parts 19, 20, and 35 of the Code of Federal
Regulatory Commission (or state agencies Regulations (CFR). Most states in the USA are agree-
ment states, meaning that they have an agreement
in Agreement States), regulate the use of
with the NRC to regulate the use of radioactive
radioactive materials including transporta-
materials within the state. Agreement state regula-
tion, handling, disposal, personnel moni-
tions have to be at least as strict as NRC regulations.
toring, and medical use.
NRC NUREG 1556 Volume 9, Revision 3 provides
ch02.indd 15 15-02-2022 16:37:19

guidance specific to radioactive materials licensing Table 2-1

for medical use and offers suggested policies and pro-
Quality Factors for Different Types of
cedures for radiation safety compliance.3 Ionizing Radiation
Radiation Quality Factor
MEDICAL USE OF RADIOACTIVE (for Converting Absorbed
MATERIALS Type of Radiation Dose to Dose Equivalent)
X-ray and gamma rays 1
Medical use of radioactive materials is defined in Part
35 of the CFR as “the intentional internal or external Beta particles 1
administration of byproduct material or the radia- Neutrons 10
tion from byproduct material to patients or human High-energy protons 10
research subjects under the supervision of an autho- Alpha particles 20
rized user.” The authorized users for nuclear cardi-
ology are physicians who meet certain training and
experience requirements and are identified on the 91% of its energy, whereas the same photon will deliver
facility’s radioactive materials license.4 Also impor- 96% of its energy to muscle tissue. Therefore, a source of
tant to the license is the Radiation Safety Officer radiation exposing a point in air to 100 R will deliver a
(RSO), a person who is responsible for implementing dose of 91 rad to fat tissue and 96 rad to muscle tissue at
the radiation protection program. The regulations the same reference point.
specify that the RSO must have independent author- Dose equivalent is a term used to quantify the
ity to stop unsafe operations and sufficient time to amount of energy deposited in tissue along with the
oversee radiation safety at the facility.3 Duties and associated biological risk from the type of radiation.2
training requirements for authorized users and RSOs The common unit for dose equivalent is Roentgen
are specified in the CFR, but it should be noted that Equivalent Man (rem), which is calculated by multi-
some agreement states have more stringent require- plying the radiation absorbed dose (rad) by a radiation
ments than the NRC. quality factor (QF).2 Table 2-1 illustrates that the QF
for x-rays, gamma rays, and beta particles is equal to 1,
whereas the QF for alpha particles is 20.6 This means
RADIOLOGICAL UNITS that an absorbed dose of 10 rads from an x-ray, gamma
ray, or beta particle equates to 10 rem (10 rad × 1),
There are several terms used when describing radia-
whereas the dose equivalent would be 200 rem
tion. These include exposure, absorbed dose, and
(10 rad × 20) if originating from alpha particulates.
dose equivalent. Named after Wilhelm Roentgen, the
Although the common units to describe the
scientist who discovered x-rays in 1895, the Roentgen
absorbed dose and dose equivalent are the rad and
(R) is the common unit of radiation exposure in air.2
rem, the international community now uses the
One Roentgen corresponds to the amount of radia-
Système International (SI) units of Gray (Gy) and
tion required to produce a charge of 2.58 × 10-4
Sievert (Sv), respectively. 1 Gy = 100 rad and 1 Sv =
Coulombs per kilogram (C/kg) in air.
100 rem. Radiation exposure is simply expressed
The Rad, or Radiation Absorbed Dose, is the mea-
as C/kg. Table 2-2 provides a summary of the units
sure of the amount of energy absorbed by an object
of radiation exposure, absorbed dose, and dose
as radiation passes through.2 The amount of energy
equivalent.
absorbed is dependent on the energy of the incident
photon and the composition of the material. The f-factor
is a tissue weighting factor used to convert exposure SOURCES OF IONIZING
in air (R) to absorbed dose (rad) in tissue taking into RADIATION EXPOSURE
account the x-ray or gamma ray energy and effective
atomic number of the tissue exposed.5 For example, a Ionizing radiation occurs naturally in the earth’s soil
100-keV gamma photon incident on fat will transfer and rock, in the cosmic rays descending from the sun
ch02.indd 16 15-02-2022 16:37:19

Chapter 2 Radiation Safety and Protection in Nuclear Cardiology 17
Table 2-2
Units of Radiation Exposure and Dose
Quantity Classical Unit International Unit (SI) Relationship
Exposure (in air) Roentgen (R) C/kg 1 R = 2.58 × 10−4 C/kg
Dose (in tissue) Radiation absorbed dose Gray (Gy) 1 Gy = 100 rad
(Rad = R × f) 1 mGy = 0.1 rad
Dose equivalent Roentgen equivalent in man Sievert (Sv) 1 Sv = 100 rem
(risk adjusted dose) (Rem = Rad × QF) 1 mSv = 0.1 rem
SOURCES OF RADIATION EXPOSURE IN THE UNITED STATES
Consumer Products Industrial and Occupational

Terrestrial (Soil) 2.0% 0.1%
3.0%
Internal
5.0%
Cosmic (Space)
5.0%
Radon and Thoron
Nuclear Medicine 37.0%
12.0%
Medical Procedures
36.0%
FIGURE 2-1 Radiation exposure sources in the United States. The U.S. population receives approximately 620 mrem (6.2 mSv)
annually, with ~50% from manmade sources (medical procedures, nuclear medicine, and consumer products) and ~50% from
background radiation. Data from NCRP Publications. NCRP Report No 160 (2015). Copyright © 2021 National Council on Radiation
Protection and Measurements. All Rights Reserved. https://ncrponline.org/publications/reports/ncrp-report-160-2/.
and stars, as well as in our own body.7 This ubiqui- x-rays and nuclear medicine procedures.9 The effec-
tous background radiation in the United States totals tive radiation dose from these sources is about equal
approximately 3.1 mSv/yr across the population.8 to that of natural sources and accounts for an addi-
Exposure to Radon and its decay products accounts tional 3.1 mSv/yr (Fig. 2-1). It is important to note
for the majority of the natural background radiation. that these estimates are population based and not all
In addition to natural background, people are individuals are exposed to radiation from manufac-
exposed to radiation in manufactured products such tured products and radiological examinations.
as smoke detectors, ceramics, and building materials, A convenient and relatable way of explaining the
as well as from medical sources including diagnostic radiation dose from medical procedures to patients
ch02.indd 17 15-02-2022 16:37:20

Table 2-3
Effective Radiation Dose from Common Examinations in Terms of Background Radiation
Single Procedure Stress/Rest
Administered Reference Reference
Examination Activity Estimated Dose Level Estimated Dose Level
201
Tl 148 MBq (4 mCi) 20.72 mSv (2.07 rem) 6.91 20.72 mSv (2.07 rem) 6.91
99m
Tc-tetrofosmin 296 MBq (8 mCi) 2.04 mSv (0.20 rem) 0.68
stress only
99m
Tc-tetrofosmin 888 MBq (24 mCi) 6.13 mSv (0.61 rem) 2.04
stress
99m
Tc-tetrofosmin 296 MBq (8 mCi) 2.04 mSv (0.20 rem) 0.68 8.17 mSv (0.82 rem) 2.72
rest
99m
Tc-sestamibi 296 MBq (8 mCi) 2.66 mSv (0.27 rem) 0.89
stress only
99m
Tc-sestamibi 888 MBq (24 mCi) 7.99 mSv (0.80 rem) 2.66
stress
99m
Tc-sestamibi 296 MBq (8 mCi) 2.34 mSv (0.23 rem) 0.78 10.33 mSv (1.03 rem) 3.44
rest
82
Rb rest or stress 1480 MBq (40 mCi) 2.52 mSv (0.25 rem) 0.84 5.03 mSv (0.50 rem) 1.68
13
N-ammonia rest 740 MBq (20 mCi) 2.00 mSv (0.20 rem) 0.67 4.00 mSv (0.40 rem) 1.33
or stress
Notes:
Reference level = Effective dose/ Yearly background dose
Dose levels for procedures data from Dorbala S, Blankstein R, Skali H, et al. Approaches to reducing radiation dose from radionuclide myocardial
perfusion imaging. J Nucl Med. 2015;56(4):592–599.
is to express the dose in terms of the yearly exposure of stress-only protocols may also be used to reduce
from natural sources.10 This is often called the refer- radiation dose. In this scenario, the stress imaging is
ence dose but may also be called by other expressions, done first and rest imaging is only performed if the
such as BERT (Background Equivalent Radiation stress image is read as abnormal.13,14
Time).11,12 Table 2-3 shows the estimated radiation
doses to patients from common nuclear cardiology
procedures and their associated reference levels. RADIATION DOSE LIMITS AND
The dose levels in Table 2-3 also illustrate the INVESTIGATIONAL LEVELS
radiation dose differences in procedures that have
led the leadership of the nuclear cardiology com- The regulations for dose limits in the United States
munity to recommend dose reduction by utilization can be found in Title 10, Part 20 of the CFR (10 CFR
of shorter half-life radiopharmaceuticals for single- 20). Table 2-4 illustrates these limits, which include
photon emission computed tomography myocar- maximum radiation dose to occupational workers, the
dial perfusion imaging (MPI) (99mTc preferred over embryo/fetus of an occupational worker, and the pub-
201
Tl). Where positron emission tomography MPI lic. Both occupational and public dose limits exclude
imaging is available, either 13N-ammonia or 82Rb will exposure to natural background radiation and radiation
result in a lower radiation dose to the patient. Use from an individual’s own medical procedures.
ch02.indd 18 15-02-2022 16:37:20

Table 2-4
Radiation Dose Limits in the United States
Area Dose Limit
Occupational worker 0.05 Sv (5 rem) per year
Whole-body total effective dose
Lens of the eye
Shallow dose to skin or extremity
Embryo/fetus of a declared pregnant 5 mSv (0.5 rem) over the gestation period
Occupational worker
Individual member of the public 1 mSv (0.1 rem) per year
Individual member of the public—special circumstance 5 mSv (0.5 rem) per year
Data from Standards for Protection Against Radiation, 10 CFR §20.1201–1208, 1301. (2020).
Table 2-5
ALARA Investigational Levels3
ALARA ALARA
Investigational Level I Investigational Level II
Area (Per Calendar Quarter) (Per Calendar Quarter)
Whole body 1.25 mSv (125 mrem) 3.75 mSv (375 mrem)
Extremity and skin 12.5 mSv (1250 mrem) 37.5 mSv (3750 mrem)
Lens of the eye 3.75 mSv (375 mrem) 11.25 mSv (1125 mrem)
While the dose limit to the public from sources to maintain radiation levels consistent with the As Low
of ionizing radiation is 1 mSv (0.1 rem) per year, this As Reasonably Achievable (ALARA) philosophy. These
limit may be increased to 5 mSv (0.5 rem) from an quarterly investigational levels may be established by
infrequent exposure related to another person’s med- the institution, or the facility may adopt those recom-
ical procedure providing the authorized user deter- mended by the NRC. As illustrated in Table 2-5, there
mines the exposure is appropriate. are two investigational levels associated with various
Because it is impractical to set occupational worker monitoring points on the body. An ALARA Level I is
dose limits to that of the public, regulators rely on the a dose equal to 10% of the annual dose limit, whereas
Linear Non-Threshold risk model to set limits at a point an ALARA Level II is triggered at 30% of the annual
below which the threshold for radiation effects are dose limit. To help ensure annual dose limits are not
known and at a point to minimize the theoretical effects exceeded, these ALARA investigational levels are rou-
from low levels of ionizing radiation exposure. The dose tinely checked on a quarterly basis.3
limits are established at levels of risk already assumed The NRC recommends that the following actions
by occupational workers.15 To this point, radiation dose must be taken when an employee exceeds ALARA
limits are established at a level where the risk of a fatal investigational levels:
cancer from occupational exposure to ionizing radia-
tion is similar to the assumed risk of a fatal work acci- ▶▶ALARA I Exceeded
dent, which is 1 in 10,000 annually.16
In addition to ensuring dose limits are not exceeded, The RSO or designee should investigate and review
an institution must adopt investigational levels in order actions that might be taken to reduce a recurrence.
ch02.indd 19 15-02-2022 16:37:20

No further action is necessary unless determined nuclear cardiology are not addressed in the regula-
otherwise by the RSO. tory guide, the recommendation for most Tc-99m-
based radiopharmaceuticals is to stop breast feeding
▶▶ALARA II Exceeded for 24 hours. No interruption is recommended for
N-13, O-15, and Rb-82, while a 4-hour interruption
The RSO should perform a timely investigation into is specified for F-18 FDG. Tl-201, on the other hand,
the cause, take action to reduce the recurrence, and calls for a 4-day suspension of breast feeding and
submit a report to the institution’s Radiation Safety clinical doses mandate that written instructions be
Committee. given to the mother.18
RELEASE OF PATIENTS ADMINISTERED

WITH RADIOACTIVE MATERIAL RADIATION BIOLOGY
Patients administered with radioactive material The deleterious risks from ionizing radiation exposure
may be released into the public provided they are are similar to exposure from other hazards encountered
not likely to expose any individual to a point where by employees in the workplace, which include both
their dose equivalent could exceed 5 mSv (0.5 rem).17 chemical and biological agents.19 Moreover, the result-
Furthermore, the patient or patient’s guardian must ing damage to cells from ionizing radiation cannot be
be provided with a set of instructions to maintain distinguished from cellular injury due to these other
doses to ALARA if the total effective dose equiva- harmful factors.20 The killing of cells directly and/or
lent to any other individual is likely to exceed 1 mSv damage to the DNA are dependent on several variables,
(0.1 rem). Breast-feeding cessation guidelines must including the caustic agent source and strength, dura-
also be provided if the dose equivalent to a nursing tion of exposure, and stage of cell growth.21,22 The effects
child could exceed 1 mSv (0.1 rem). are classified as either stochastic, where the probability
NRC Radiation Guide 8.39, “Release of Patients of occurrence increases with dose, or deterministic, in
Administered Radioactive Material,”18 provides guid- which the severity increases with dose, after a threshold
ance for the release of patients, administered activities is exceeded (Fig. 2-2).23 Stochastic effects include can-
of radiopharmaceuticals requiring instructions, and cer and genetic manifestations, whereas deterministic
breast-feeding. Diagnostic doses of all radiopharma- effects include reddening of the skin (erythema) and
ceuticals used in nuclear cardiology fall well below development of cataracts.
the limit that would prohibit release of the patient. The source and intensity of radiation play a par-
For example, the patient would have to have 28 GBq ticular role in assessing risks from exposure. While
(760 mCi) of Tc-99m on-board to prevent release. both stochastic and deterministic risk effects are
While recommendations for cessation of breast feed- dose dependent, meaning risk increases with radia-
ing for the Tc-99m radiopharmaceuticals used in tion energy and duration of exposure, these effects
Probability Severity
Stochastic Deterministic
effects effects
FIGURE 2-2 Stochastic and deterministic effects from

exposure to radiation. The effects from radiation exposure
are classified as either (A) stochastic—the probability
for the effect to appear increases with radiation dose or
(B) deterministic—the severity of the effect increases with
radiation dose only after a dose threshold is exceeded. A Radiation dose B Radiation dose
ch02.indd 20 15-02-2022 16:37:21

are heightened by the type of radiation. X-rays and cellular DNA. This may leave the cell modified yet
gamma rays are high-energy quanta of electromag- still viable.16
netic radiation characterized by short wavelengths
and high frequencies that have the ability to ionize
an exposed atom. The biological effectiveness, or the RADIATION PROTECTION PRINCIPLES
risk adjusted for radiation quality, for x-rays, gamma
rays, and beta particles is the same (Table 2-1). On Occupational workers exposed to ionizing radiation
the other hand, alpha emissions are high-energy must practice radiation safety techniques on a daily
particulate radiation that deposits significantly more basis to maintain levels of exposure below federal
energy as it passes through tissue. Because of this dose limits. To assess the levels of cumulative expo-
increased transfer of energy, alpha particles bear a sure, occupational workers are issued personal radia-
higher biological risk than x-rays, gamma rays, and tion monitors. When a pregnant worker declares her
beta particles. At equivalent doses of radiation, the pregnancy status, an additional monitor is provided
associated biological risk from alpha emissions is to be worn at the waist level for assessing the radia-
20 times that of x-rays, gamma rays, and beta particles. tion dose to the fetus.
When exposed to radiation, cells can be affected Over and above the universal precautions common
directly by energy deposited into the atom/molecule to the healthcare environment, there are three cardinal
or indirectly through ionization of the surround- rules in the protection against ionizing radiation. These
ing medium, which then interacts with the target are time, distance, and shielding (Fig. 2-3).24
cells. Whether directly or indirectly via free radical
production in cellular water, the toxic effects from ▶▶Time
radiation exposure include the removal of an elec-
tron from DNA molecules causing single- or double- Radiation is emitted as a rate. A radiation source
strand breaks. Double DNA strand breaks are overly emitting photons or particles at a rate of 80 mGy/hr
traumatic and often lead to cellular death. Although would expose a particular area to 80 mGy in 1 hour.
single-strand breaks frequently repair themselves Understanding this principle, occupational workers
correctly, incorrect or mutagenic repairs do occur. limit their time around known radiation sources,
A mutagenic repair represents a change in the which in turn limits their cumulative exposure. In
Spending less time near source Increasing distance from source Increased shielding
lessens radiation exposure lessens radiation exposure lessens radiation exposure
A B C
FIGURE 2-3 Principles of radiation protection. From http://www.nrc.gov/about-nrc/radiation/protects-you/protection-principles.html.
The three rules for protection from radiation are (A) reduce your time around a source, (B) increase your distance from the source,
and (C) use appropriate shielding devices.
ch02.indd 21 15-02-2022 16:37:21

the example given above, a worker exposed to an radiation source and strength. Concrete and lead of var-
80-mGy/hr source would only receive 40 mGy of ious thicknesses are commonly used in barriers to pro-
exposure if his or her time around the source were vide structural protection to occupational workers and
limited to 30 minutes. the general public. Partial barriers, lead-lined transport
containers, and lead-lined syringe shields are also used
▶▶Distance to protect radioisotope workers during the preparation
and administration of radiopharmaceuticals.
Like a source of visible light that appears dimmer at
increased distances, ionizing radiation decreases in PERSONNEL MONITORING
intensity as well. The inverse square law states that the
intensity of radiation decreases with the inverse of the Occupational radiation workers are required to be
square of the distance, or I1(d1)2 = I2(d2)2, where I = monitored for radiation exposure if they are likely
intensity and d = distance. Radiation is emitted in an to enter a high or very high radiation area, are likely
isotropic manner. As distance increases, the same flux of to exceed 10% of the annual dose limits, or are a
radiation covers a larger surface area, thereby decreas- declared pregnant woman likely to receive an annual
ing the exposure to a finite object in the path (Fig. 2-4). dose in excess of 1 mSv (0.1 rem).25
Continuing the previous example, a worker exposed to There are several types of personnel monitors
40 mGy at 1 meter from a radiation source will reduce used in nuclear cardiology facilities. These include the
their exposure to 10 mGy at a distance of 2 meter. film badge, a thermo luminescent dosimeter (TLD),
Example: and an optically stimulated luminescence (OSL)
device. The NRC requires evaluation of these devices
by a laboratory that is accredited by the National
I1 × (d1)2 = I2 × (d 2)2
Voluntary Laboratory Accreditation Program.
40 mGy × (1 m)2 = I2 × (2 m)2 Film badges utilize a strip of photographic film
40 mGy = I2 × 4 contained in a plastic holder. Exposure to radiation
will increase the darkening in the developed film. The
I2 = 10 mGy
degree of darkening is proportional to the radiation
exposure received. Incorporated into the badge holder
▶▶Shielding are filters such as lead, copper, aluminum, and plastic.
The degree of darkening behind each filter helps deter-
Shielding is often used to provide a protective barrier mine the quality of the radiation received, such as high-
between a worker and a radiation source. The shield- energy photons, low-energy photons, and particulate
ing material and thickness are dependent upon the radiation. Film badges are commonly used to measure
I1(d1)2 = I2(d2)2
FIGURE 2-4 The Inverse Square Law.

Radiation intensity is reduced with the
inverse of the square of the distance from
a source. A radiation source exposing
material to 80 mGy/hr at 1 meter results
in only 20 mGy/hr at a distance of 2 meter.
(80) / (2)2 = 20 mGy/hr = 10 mGy per Distance 1 meter 2 meters
30 minutes. Exposure 80 mGy/hr 20 mGy/hr
ch02.indd 22 15-02-2022 16:37:22

whole-body irradiation and are comparatively inexpen- c. An administration of a radiopharmaceutical to

sive. However, they are affected by heat, moisture, and the wrong person
sunlight and must be utilized with care. d. An administration of a radiopharmaceutical by
TLDs use inorganic crystals such as lithium fluo- the wrong route (i.e., oral vs. intravenous)
ride to measure radiation exposure. When exposed
to ionizing radiation, excitation of atoms causes elec-
trons to elevate from their valence band to become POSTINGS
trapped in the forbidden band. When heated with There are several postings required in a nuclear car-
high temperatures (annealing), the electrons are diology laboratory. These include the “Notice To
released back into the valence band emitting light Employees” (NRC Form 3) and appropriate radiation
proportional to the radiation received. By returning caution signage.26–28 NRC Form 3 outlines employee/
to their stable state, the annealing process allows the employer responsibilities for protection against radia-
TLD to be re-used. TLDs do not have the ability to tion and is required to be posted in a conspicuous
distinguish radiation quality and are commonly used manner and replaced if defaced or altered.29 This form
as extremity monitors, such as the ring badge.
should be posted in an area frequented by workers either
OSL combines the benefits of film badge and TLD
on their way to or from the area where radiation is used
technology. An aluminum oxide crystalline structure is
or stored. This form is commonly found in employee
manufactured into a thin strip and placed between a fil-
lounges and entrance doors to radiation areas.
ter pack. Irradiated atoms in the structure liberate elec-
A “Caution Radioactive Materials” sign (Fig. 2-5)
trons that become trapped, and these electrons release
is required to be posted in any area where radioactive
light when stimulated by a laser. The release of light is
materials are used or stored that exceed 10 times the
proportional to the radiation received. Similar to that in
quantity listed in Appendix C of Title 10, Part 20 of
film badge technology, plastic and metal filters are used
the Code of Federal Regulation. This equates to 1 mCi
to assess the incident radiation quality. OSL devices are
of 57Co, 0.1 mCi of 137Cs, and 10 mCi of 99mTc and
commonly used for whole-body radiation monitoring. 201
Tl. A “Caution Radiation Area” sign is required to
The devices are sealed in a blister pack and are unaf-
be posted in each area where radiation levels could
fected by light, heat, and moisture.
result in an individual receiving 0.05 mSv (5 mrem)
in 1 hour at 30 cm from a radiation source. Caution
MEDICAL EVENTS signs are commonly located on the entrance doors to
the hot lab, imaging room, and injection areas such
Once known as misadministrations, medical events as the treadmill room. If a radioactive material is
are defined by the NRC in Part 35 of the CFR. The used in a room for less than 8 hours per day and is
NRC must be notified by telephone of a reportable under constant supervision, the area is not required
medical event no later than the next calendar day to be posted with the caution sign. Furthermore, a
after occurrence. The telephone notification must be
followed by a written report within 15 days. Pertinent
to nuclear cardiology, the following events must be
reported to the NRC if they result in a dose equivalent
to the patient that exceeds 0.05 Sv (5 rem) or a dose
to the skin or an organ that exceeds 0.5 Sv (50 rem).
Events meeting these definitions but not exceeding
the reportable dose limits need only be documented
and reported to the facility’s administrators.
a. An administration of a dose that is greater than
20% difference from the prescribed dose
b. An administration of the wrong radiopharma - FIGURE 2-5 Radiation caution signs found in nuclear
ceutical cardiology laboratories.
ch02.indd 23 15-02-2022 16:37:23

radiation area sign is not needed if the source of the 2. Prevent the spread of contamination by covering the
exposure is from a patient meeting the criteria to be spill with absorbent paper labeled “caution radioac-
released into the public. tive material,” but do not attempt to clean it up.
3. Shield the source if possible. Do this only if it can
AREA SURVEYS AND SPILL PROCEDURES be done without further contamination or a sig-
nificant increase in radiation exposure.
Ambient radiation level surveys must be performed 4. Close the room and lock or otherwise secure the
at the end of each working day in areas where radio- area to prevent entry.
active materials are used and stored. The most com- 5. Notify the RSO immediately.
mon instrument for performing ambient radiation 6. Decontaminate personnel by removing contami-
surveys in the Nuclear Cardiology department is nated clothing and flushing contaminated skin
the Geiger–Müller (GM) meter, a gas-filled detector with lukewarm water, and then washing with mild
that produces and collects ion pairs when ionizing soap. If contamination remains, the RSO may
radiation passes through the detector and deposits consider inducing perspiration. Then wash the
energy. The NRC recommends an ambient expo- affected area again to remove any contamination
sure trigger limit of 5 mR/hr in restricted areas and that was released by the perspiration.
0.1 mR/hr in unrestricted areas.3
Removable contamination surveys (wipe tests) WASTE DISPOSAL
should be performed weekly using an appropriate
gamma-counting device such as a sodium iodide (NaI) Radioactive waste generated in the Nuclear Cardio
well counter. While Appendix R of NRC NUREG logy department may be disposed by various meth-
1556 Volume 93 suggests an action level of 20,000 ods. The two most common are decay-in-storage and
disintegrations per minute (dpm)/100 cm2 for 99mTc return to an authorized recipient. Decay-in-storage
and 201Tl, many nuclear cardiology facilities use the is allowed for isotopes with a half-life of 120 days or
2000 dpm/100 cm2 action level required for other iso- less.30 Storage of waste for decay requires that the
topes common in general nuclear medicine depart- waste to be held for a minimum of 10 half-lives in
ments. It is also important to verify ambient radiation a shielded container and prior to final disposal the
and contamination limits in your individual area of prac- waste must be surveyed to ensure it is consistent with
tice as many states have more restrictive requirements. background radiation. All radioactive labels must be
When ambient radiation levels or contamination removed or defaced, and a record of the waste dis-
surveys exceed limits, a radiation spill has occurred posal must be maintained for 3 years. A summary of
requiring action. The NRC recommends establishing an the minimum length of time radioactive waste must
activity threshold for a major and minor spill and pro- be held in storage for isotopes common to nuclear
vides guidance in Appendix N of NRC NUREG 1556 cardiology is summarized in Table 2-6.
Volume 9.3 The suggested procedures are as follows:
Minor Spill (less than 100 mCi of 99mTc/201Tl)
1. Notify persons in the area that a spill has occurred.
2. Prevent the spread of contamination by covering Table 2-6
the spill with absorbent paper. Minimum Time Required for Decay-in-Storage
3. Wear gloves and protective clothing and clean up Minimum Time in
the spill using absorbent paper. Isotope Half-Life Storage (10 half-lives)
4. Survey the area with appropriate radiation detec-
99m
tion instruments. Tc 6.01 hours 60.1 hours
5. Report the incident to the RSO. 201
Tl 72.9 hours 30.4 days
18
Major Spill (greater than 100 mCi of 99m 201
Tc/ Tl) F 1.83 hours 18.3 hours
13
N 9.96 minutes 1.7 hours
1. Clear the area. Notify all persons not involved in 82
R 1.3 minute 13 minutes
the spill to vacate the room.
ch02.indd 24 15-02-2022 16:37:23

FIGURE 2-6 DOT labels for shipping radioactive packages. From left to right: The Radioactive I “White,” Radioactive II “Yellow,”
Radioactive III “Yellow,” and the Excepted Package Limited Quantity.
Radioactive waste, including used and unused sources. Shipping of radioactive materials is regulated
doses, may also be transferred to an authorized recipi- by the DOT under Title 49 of the CFR.
ent. Transfer of the waste requires verification that the There are four DOT labels used for shipping
recipient is licensed to receive the specified radioactive radioactive materials (Fig. 2-6). The use of each label
material. Furthermore, when transferring this radio- is determined by the quantity of material in the pack-
active material, the facility must follow Department age and the radiation exposure at the surface and at
of Transportation (DOT) shipping guidelines. A sum- 1 meter from the package.
mary of these requirements is outlined in the “Shipping The most common radioactive package shipped
of Radioactive Packages” section. from the Nuclear Cardiology department is the
“UN2910—Excepted Package, Limited Quantity.” For
RECEIVING a package to ship under the specifications of UN2910,
the maximum quantity in the package cannot exceed
Receipt of radioactive packages is outlined in Title 10, the limits derived from the table in 49CFR173.425.
Part 20.1906 of the CFR. Radioactive packages must Furthermore, the following criteria must be met:
be monitored within 3 hours of delivery if received
a. The surface of the package must not exceed
during normal working hours and no later than
0.5 mR/hr.
3 hours from the beginning of the next working day
b. A wipe test of the package must not exceed
if received after normal hours. Proper monitoring
6600 dpm/300 cm2.
requires surveying the package for external radiation
exposure and wipe testing for removable contamina- The limited quantity package limits for common
tion. Radiation surveys must be less than 10 mR/hr at isotopes derived from 49CFR173.425 are illustrated
1 meter and less than 200 mR/hr at the package surface. in Table 2-7. The limits apply to radioactive material
Contamination wipe testing must be performed if there
is suspicion that the package is damaged or the integrity Table 2-7
is degraded in any manner. The wipe test results must
be less than 6600 dpm/300 cm2. Should the wipe test or “Excepted Package Limited Quantity” Limits for
Common Isotopes Used in Nuclear Cardiology
survey results exceed limits, the delivery carrier and the
NRC must be notified immediately.31 Isotope Form Limit
99m
Tc Liquid 11 mCi
SHIPPING OF RADIOACTIVE PACKAGES 201
Tl Liquid 11 mCi
18
In addition to receiving radioactive materials, the F Liquid 1.6 mCi
Nuclear Cardiology department must routinely ship 57
Co Liquid 27 mCi
radioactive materials. These shipments include the 137
Cs Liquid 1.6 mCi
return of spent and unused patient radiopharmaceu- 68
Ge Solid 14 mCi
tical doses, as well as the return of sealed calibration
ch02.indd 25 15-02-2022 16:37:24

Table 2-8
DOT Label Radiation Exposure Limits
DOT Label Surface Exposure (mR/hr) 1 M Exposure (mR/hr) Wipe Test Limit
a
Excepted Package Limited Quantity ≤0.5 Background 6600 dpm/300 cm2
White I ≤0.5 Background 6600 dpm/300 cm2
Yellow II >0.5 ≤50 1.0 6600 dpm/300 cm2
Yellow III >50 ≤200 10 6600 dpm/300 cm2
a
The Excepted Package Limited Quantity label conforms to White I limits and the contents of the package meet the specifications of 49CFR173.425.
in both solid and liquid forms. For packages contain- NRC NUREG 1556 Volume 9 Revision 3 provides a
ing more than one isotope, the lower limit applies to sample policy that facilities may choose to adopt in
the entire contents of the package. lieu of developing their own.3 The NRC policy for the
A radioactive package that exceeds the excepted safe use of radioactive materials provides a basis for
package quantities has a surface exposure of less than establishing a safe working environment. The model
0.5 mR/hr, an exposure at 1 meter that is indistin- policy covers proper protective clothing, shielding
guishable from background, and a wipe test of less and handling requirements, safe storage procedures,
than 6600 dpm/300 cm2 receives a Radioactive I procedures for area monitoring, and, most impor-
“White” label. tantly, patient safety.
A Radioactive II “Yellow” label is used for pack-
ages with a surface exposure of 0.5 to 50 mR/hr, a
1-meter exposure of less than 1 mR/hr, and a wipe REFERENCES
test of less than 6600 dpm/300 cm2. The Radioactive
II label is commonly used when shipping calibration 1. The Health Physics Society. 2014. http://hps.org/publicinfor
sources back to the vendor for disposal. mation/ate/faqs/whatisradiation.html. Accessed August 23,
2020.
Packages with a surface exposure of 50 to 200 mR/hr,
2. United States Nuclear Regulatory Commission. 2014. http://
a 1-meter exposure of less than 10 mR/hr, and a wipe www.nrc.gov/reading-rm/basic-ref/glossary.html. Accessed
test of less than 6600 dpm/300 cm2 must be labeled August 23, 2020.
with a Radioactive III “Yellow” label. 3. Burkhart M, Cockerham A, Cook J, et al. Consolidated Guid-
ance About Materials Licenses Program-Specific Guidance
Radioactive labels must be placed onto two About Medical Use Licenses. US NRC NUREG-1556, volume 9
sides of the package and packages requiring the revision 3) 2019.
Radioactive I, II, or III label must be classified as a 4. Baldwin JA, Bag AK, White SL, Palot-Manzil FF, O’Malley JP.
“Type A” shipping container. A “Type A” shipping AJR Am J Roentgenol. 2015;205(2):251–258.
5. Cherry SR, Sorenson JA, Phelps ME. Radiation safety and health
container is a strong package that has met certain physics. In: Cherry SR, Sorenson JA, Phelps ME, eds. Physics in
criteria including a water spray test, drop test, com- Nuclear Medicine. 4th ed. Philadelphia, PA: Saunders/Elsevier
pression test, and a penetration test. A summary of Science;
the radiation exposure limits for each DOT label is 6. Standards for Protection Against Radiation, 10 CFR § 20.1004
(2018).
illustrated in Table 2-8. 7. United States Nuclear Regulatory Commission. 2017. http://
www.nrc.gov/about-nrc/radiation/around-us/sources/
nat-bg-sources.html. Accessed August 23, 2020.
www.nrc.gov/about-nrc/radiation/around-us/sources.html.
SAFE USE OF RADIOACTIVE MATERIAL Accessed August 23, 2020.
The NRC requires licensees to develop a policy for www.nrc.gov/about-nrc/radiation/around-us/sources/man-
the safe use of radioactive materials. Appendix T of made-sources.html. Accessed August 23, 2020.
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10. Peck D, Samei E. How to Understand and Communicate 20. Travis EL. Basic biologic interactions of radiation. In: Kelly
Radiation Risk. Image Wisely, 2017. https://www.imagewisely. KM, ed. Primer of Medical Radiobiology. St. Louis, MO:
org/-/media/Image-Wisely/Files/CT/IW-Peck-Samei-Radia Mosby-Yearbook, Inc.; 1989:25–44.
tion-Risk.pdf. Accessed August 23, 2020. 21. Bushberg JT, Boone JM. Radiation biology. In: Mitchell CW,
11. Cameron JR. Are X-rays safe? http://www.angelfire.com/mo/ ed. The Essential Physics of Medical Imaging. Baltimore, MD:
radioadaptive/jcameron1.html. Accessed August 23, 2020. Lippincott Williams & Wilkins; 2011:600, 751–836.
12. Nickoloff EL, Lu ZF, Dutta AK, So JC. Radiation dose descrip- 22. Valentin J. ICRP publication 84: Pregnancy and medical radi-
tors: BERT, COD, DAP, and other strange creatures. Radio- ation. Ann ICRP. 2000;30, 7–67.
graphics. 2008;28(5):1439–1450. 23. Adriaens I, Smitz J, Jacquet P. The current knowledge on
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principles.html. Accessed August 23, 2020.
imaging. J Nucl Cardiol. 2010;17(4):709–718.
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ch02.indd 27 15-02-2022 16:37:24


Radiopharmaceuticals for CHAPTER
Cardiovascular Imaging
James A. Case and Gary V. Heller

3
photons center at 72 keV and photons at 137 keV
KEY POINTS and 167 keV) made scatter and attenuation correc-
tion difficult.4,5 By the early 1990s, investigations
■■ Ideal tracer kinetics is important in under-
were underway with using 99mTc.6–12 This isotope has
standing the strengths and limitations of
the advantage of a single-emission photon at 141 keV
current and future tracers.
and a more ideal half-life of 6 hours. Thus image
■■ Thallium-201 has excellent tracer kinetics quality would be improved and radiation exposure
but is limited by low-energy emission level reduced over thallium.12 This agent could be pre-
and long half-life, and therefore is not rec- pared at a centralized radiopharmacy and delivered
ommended for routine clinical use. for use to nearby nuclear cardiology laboratories.
■■ Technetium-based tracers offer improved Alternatively, 99mTc could be produced from a molyb-
image quality due to higher emission level denum generator located at the radiopharmacy. 99mTc
and shorter half-life and are the radiophar- sestamibi, 99mTc tetrofosmin, and 99mTc teboroxime
maceuticals of choice for single-photon were subsequently developed to assess myocardial
emission computerized tomographic nuclear blood flow.13,14 Sestamibi and tetrofosmin are still in
cardiology. widespread use today, while teboroxime is not, due to
■■ The most common positron emission tomog- clinical limitations. The development of technetium-
raphy tracer, 82Rb, is generator-derived radio- based tracers for nuclear cardiology led to a more
pharmaceutical, with excellent blood flow widespread use of myocardial perfusion imaging
characteristics and low radiation, making it (MPI) that has continued through the present time.
suitable for most clinical practices. Positron emission tomography (PET) radiotrac-
ers were also undergoing revolutionary changes.
Positron emitting isotopes of oxygen, carbon, nitro-
INTRODUCTION gen, and fluorine could all be used for producing
metabolically useful molecules. In 1996, Medicare
Myocardial perfusion scintigraphy has significantly approved reimbursement for glucose analog, 18F-
evolved since its introduction more than four decades fluorodeoxyglucose (FDG), for the assessment of
ago. In 1972, the only radiotracer available for nuclear metabolically active tumors. This stimulated the
cardiology was 201Tl.1–3 Although this agent had development of cyclotron networks for producing
impressive characteristics for the assessment of myo- the 18F and marked improvements in PET scanners
cardial blood flow, its long half-life (72 hours) and the opened the door to high-quality PET MPI using a
multiple emission energy photons (numerous Auger generator-based potassium analog, 82Rb.15–18 This
ch03.indd 29 15-02-2022 13:51:55

allowed for on-site production of a short-lived posi- radiopharmacy to the nuclear laboratory or its
tron emission agent without the need for an expen- production would be sufficiently simple to allow
sive cyclotron. on-site production.
This chapter will review important characteristics
of the various single-photon emission computerized
tomographic (SPECT) and PET MPI radioactive KINETIC MODELING FOR
agents used in clinical practice, with an increasing MYOCARDIAL BLOOD FLOW
focus on quantitative myocardial blood flow mea-
surement. The emphasis of this chapter is to provide A recent development of nuclear cardiology has been
the nuclear cardiologists with practical knowledge of the ability to quantitate myocardial blood flow in
these agents and a high-level understanding of the conjunction with perfusion imaging. This has added
direction of radiopharmaceutical development. considerably to the diagnostic accuracy, as well as
risk stratification in nuclear imaging. Myocardial
blood flow assessment is becoming commonplace in
IDEAL PHYSIOLOGIC CHARACTERISTICS clinical cardiac PET laboratories, and work is con-
OF PERFUSION IMAGING AGENTS tinuing to make it practical at least for some SPECT
systems (Chapter 11). Calculating myocardial blood
The commercially available radionuclides for MPI
flow from measurements of radiotracer uptake and
have advantages and disadvantages. To understand
blood pool concentration requires a model for tracer
these advantages and dispensers, it is important to
transport into myocytes. The most common model
enumerate the characteristics of an “ideal” myocar-
for tracer transport is a multi-compartment model.
dial blood flow tracer:19–21
Each compartment of the model represents a loca-
• Myocardial uptake of an ideal perfusion radio- tion the tracer can be in during the acquisition. In the
tracer should be proportional to the myocardial simplest model, the tracer would begin in the blood
blood supply over a wide range of myocardial (compartment one) and then be transported into the
blood flow values including both exercise and cell (compartment two) (Fig. 3-1). More complicated
pharmacologic stress. models would include parameters for washout from
• Uptake of the radiotracer should allow for delin- the myocyte, compartments for the interstitial layer,
eation of regional changes in uptake and sufficient metabolism of the tracer, and different subcompo-
signal-to-noise to make confident image interpre- nents within the cell.
tation decisions. The choice of a compartmental model for calcu-
• Uptake in noncardiac structures should not inter- lating myocardial blood flow is based on the underly-
fere with the reconstruction and interpretation of ing kinetics of the tracer and the parameters of the
the myocardium. acquisition. In addition, the choice of a compart-
• Uptake of the radiotracer should be rapid enough mental model should take into consideration com-
to allow complete absorption of the radiotracer mon imaging artifacts, such as image noise, patient
within the peak vasodilatation timing window of motion, and noncardiac uptake.
either exercise and/or pharmacologic stress. Most myocardial perfusion tracers are modeled
• Uptake of the radiotracer should be stable through- accurately using a two-tissue compartment model
out the course of perfusion imaging acquisition. (2TCM), where one compartment represents the blood
• Rest/stress patient radiation doses should be less and the two-tissue compartments represent the cell, an
than 10 mSv while maintaining a high-count high- interstitial layer, or subcomponent in the cell:22
resolution tomographic images of the heart.
• The complete rest stress protocol should be com- K1k2 −(k2 + k3)t K1k3 t
pleted in a single visit to the nuclear laboratory for

Cm =
k2 + k3
e ⊗ Ca(t) + ∫
k2 + k3 0 a
C (τ)dτ
the majority of patients.
• The radiotracer should be either sufficiently where Cm is the myocardial uptake, K1 is the uptake
stable to allow for same-day delivery from the into the first tissue compartment, k2 is the washout
ch03.indd 30 15-02-2022 13:52:05

Another random document with
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Hän nauroi tunnottomasti, mutta hillitysti. Laihat kasvot, tummat
viikset ja vaaleneva tukka antoivat hänelle kuvaamattoman
terävyyden ilmeen.
»Minä en ole kuningas», sanoi hän. »Sitäpaitsi on minulle kerrottu,

että te olette surmannut vähintään kuusi henkilöä kaksintaistelussa.
Olette sentähden kuninkaalle velkaa ainakin yhden elämän. Teidän
on se maksettava. Meillä ei näy olevan muuta sanomista
toisillemme, herra de Berault», jatkoi hän kylmästi, kääntyen pois ja
ryhtyen keräämään kokoon joitakin papereita. »Lain täytyy tehdä
tehtävänsä.»
Hän tuntui olevan antamaisillaan vartioupseerille viittauksen viedä

minut pois, ja kylmä hiki alkoi virrata pitkin selkääni. Näin
mestauslavan edessäni, tunsin nuoran kaulassani. Silmänräpäys
vielä, ja kaikki olisi myöhäistä!
»Minulla on suosionosoitus anottavana», änkytin toivottomana,

»jos teidän ylhäisyytenne suo minulle hetkeksi yksityispuhelun.»
»Missä tarkoituksessa?» vastasi hän kääntyen katselemaan

minua kylmäkiskoisen tyytymättömästi. »Tunnen teidät —
entisyytenne — kaikki. Siitä ei ole mitään hyötyä, ystäväiseni.»
»Ei siitä ole ainakaan vahinkoa!» huudahdin minä. »Ja minä

seison haudan partaalla, monseigneur!»
»Se on totta», vastasi hän miettivästi. Hän näytti yhä epäröivän, ja

sydämeni pamppaili. Viimein hän katsoi upseeriin. »Saatte mennä»,
sanoi hän lyhyesti. »No», jatkoi hän, kun olimme jääneet kahden
kesken. »Mistä kysymys? Sanokaa pian, mitä mielessänne on. Ja
ennen kaikkea, älkää koettako pitää minua narrinanne herra de
Berault.»
Mutta hänen läpitunkevat silmänsä veivät minulta nyt siinä määrin

kaiken mielenmaltin, kun olin saanut haluamani tilaisuuden ja
päässyt puhuttelemaan häntä kahden kesken, etten keksinyt
sanaakaan lausuakseni, vaan seisoin ihan mykkänä hänen
edessään. Hän näytti tulevan siitä hyvilleen, sillä hänen kasvonsa
saivat vähemmän ankaran ilmeen.
»No?» sanoi hän viimein. »Siinäkö kaikki?»
»Mies ei ole kuollut», sopersin minä.
Hän kohautti ylenkatseellisesti olkapäitään.
»Entä sitten?» sanoi hän. »Sitä ette aikonut minulle sanoa.»
»Pelastin kerran teidän ylhäisyytenne hengen», sopersin

surkeasti.
»Myönnetään», vastasi hän ohuella, terävällä äänellään. »Sen

tosiseikan mainitsitte äsken. Toiselta puolen olette minunkin
tietääkseni sammuttanut kuusi ihmishenkeä, herra de Berault. Olette
viettänyt riitelijän, alhaisen pukarin ja pelaajan elämää. Ja kuitenkin
olette hyvää syntyperää! Häpeä kerrassaan! Ihmettelettekö, että nyt
olette joutunut tähän? Mutta tuon yhden seikan takia kuuntelen teitä
vielä», lisäsi hän samassa.
»Voisin pelastaa teidän ylhäisyytenne hengen jälleen», huudahdin

minä.
Se oli äkillinen mieleenjohtuma.
»Tiedätte jotakin?» sanoi hän nopeasti ja tähysteli minua. »Ei»,
jatkoi hän ja pudisti päätään. »Vielä mitä! Vanha veruke. Minulla on
parempia vakoojia kuin te, herra de Berault.»
»Mutta ei parempaa miekkamiestä!» huudahdin minä käheästi. »Ei

koko henkivartiossanne.»
»Se on totta», sanoi hän verkalleen. »Se on totta.»

Kummastuksekseni hän lausui tämän harkitsevaan tapaan, ja katseli
alas eteensä. »Malttakaas, kun mietin, ystäväiseni», jatkoi hän.
Hän asteli pariin kolmeen kertaan edestakaisin huoneessa, minun

seistessäni vavisten. Vavisseeni tunnustan. Mies, jonka valtimoa ei
vaara kykene jouduttamaan, on harvoin yhtä luja jännitystä vastaan,
ja se äkillinen toivo, jonka hänen sanansa herättivät mielessäni,
järkytti minua siinä määrin, että tuskin näin häntä selvästi, kun hän
kuulumattomin askelin käveli edestakaisin, vierellään kissa, joka
hankasi kylkeään hänen pitkään kauhtanaansa ja kääntyi aina
yhtaikaa hänen kanssaan. Tartuin pöydän laitaan, saadakseni tukea.
En ollut edes itselleni tahtonut tunnustaa, kuinka synkkänä
Montfauconin ja hirsipuun varjo oli kuvastunut edessäni.
Sain aikaa tyyntyäkseni, sillä kesti jonkun aikaa ennenkuin hän

puhui.
Hänen äänensä oli nyt kova, muuttunut ja käskevä.
»Teillä on se maine, että olette ainakin uskollinen sitä kohtaan,

joka käyttää teitä», sanoi hän. »Älkää vastatko minulle. Sanon, että
niin on. No, tahdon luottaa teihin. Annan teille vielä yhden tilaisuuden
— vaikka se onkin epätoivoinen. Voi teitä, jos ette onnistu!
Tunnetteko Cocheforêtia Béarnissa? Se on lähellä Auchia.»
»En, teidän ylhäisyytenne.»
»Ettekä myöskään herra de Cocheforêtia?»
»En, teidän ylhäisyytenne.»
»Sitä parempi», vastasi hän. »Mutta olette kuullut puhuttavan

hänestä. Hän on ollut osallisena jokaiseen gascognelaisvehkeeseen
edesmenneen kuninkaamme kuolemasta saakka ja tuotti meille
enemmän kiusaa Vivaraisissa viime vuonna kuin kukaan muu häntä
kaksin verroin vanhempikaan on saanut aikaan. Nyt hän on
Bosostissa Espanjassa muiden karkulaisten seurassa, mutta minä
olen kuullut, että hän käy usein tervehtimässä vaimoaan
Cocheforêtissa, joka on kuuden lieuen päässä tällä puolella rajaa.
Tuollaisella vieraskäynnillä pitää hänet vangita.»
»Se käy helposti päinsä», sanoin minä.
Kardinaali katsahti minuun.
»Typeryyksiä! Mitä te siitä tiedätte?» vastasi hän äreästi. »Jos joku

sotilas kävelee kadun poikki Auchissa, tiedetään se heti
Cocheforêtissa. Talossa on vain pari kolme palvelijaa, mutta heillä on
puolellaan koko maalaisväestö, ja se on vaarallista liutaa. Yksi kipinä
voisi sytyttää uuden kapinan. Vangitsemisen täytyy sentähden
tapahtua salaisesti.»
Minä kumarsin.
»Päättäväinen mies perheen piirissä», jatkoi kardinaali ja katseli

ajatuksissaan muuatta paperia, joka oli pöydällä, »voisi toimittaa
sen, jos hänellä olisi pari kolme palvelijaa tarpeen tullen
kutsuttavissa avukseen. Nyt on kysymyksessä, haluatteko te olla se
mies, ystäväiseni?»
Minä epäröitsin; sitten kumarsin. Minullahan ei ollut valitsemisen

varaa.
»No, sanokaa pois!» käski hän terävästi. »Kyllä vai eikö, herra de
Berault?»
»Kyllä, teidän ylhäisyytenne», sanoin vastahakoisesti. Sanon vielä

kerran, oliko minulla muuta valittavaa?
»Te tuotte hänet Pariisiin, mutta elävänä. Hänen tiedossaan on

eräitä asioita, ja sentähden minä tahdon hänet tänne.
Ymmärrättehän?»
»Kyllä ymmärrän, monseigneur.»
»Saatte hankkia pääsyn linnaan miten parhaiten voitte», jatkoi hän

painavasti. »Teidän tulee ryhtyä toimeen ovelasti ja valtioviisaasti.
Ne epäilevät kaikkia. Teidän on johdettava heidät harhaan. Jos ette
onnistu siinä tai onnistuttuanne joudutte ilmi, en usko teidän
vaivaavan minua enää toistamiseen tai ainoatakaan kertaa
loukkaavan kaksintaistelukieltoa. Jos taasen petätte minut» — hän
hymyili vielä ovelammin, ja hänen äänensä sai kähisevän soinnun —
»niin saatte tutustua teilauslavaan; silloin olette hävinnyt pelinne.»
Kohtasin hänen katseensa pelottomasti. »Niin tapahtukoon!»

vastasin rauhallisesti. »Jos en tuo herra de Cocheforêtia Pariisiin,
niin menetelkää minun suhteeni siten — ja vielä pahemminkin!»
»Se on sovittu», sanoi hän verkalleen. »Luotan siihen, että olette

uskollinen. Ja mitä rahoihin tulee — tässä on sata kultakolikkoa. Se
kyllä riittää siihen, mutta jos onnistutte, saatte vielä saman verran
lisää. Niin, siinä kaikki, mitä tarvitsee sanoa. Ymmärrätte?»
»Kyllä, monseigneur.»
»Mitä sitten odotatte?»
»Vankilanpäällikkö…?» sanoin minä nöyrästi.
Kardinaali nauroi itsekseen, heittäytyi istumaan ja kirjoitti

muutamia sanoja paperilapulle. »Antakaa hänelle tämä», sanoi hän
leikkisänä. »Minä pelkään, herra de Berault, että te ette milloinkaan
saa palkkaanne — tässä maailmassa.»
II luku
»Vihreässä pilarissa»
Cocheforêt sijaitsee mäkisellä seudulla, missä kasvaa tammia,

pyökkejä ja kastanjapuita ja syvät, vehmaat laaksot vihannoitsevat
metsäisten kunnaiden lomissa. Harjanteina ja notkoina, ahoina ja
kukkuloina ulottuu tämä harvaan asuttu ja vielä niukemmin viljelty
metsätienoo niille korkeille lumihuippuisille vuorille saakka, jotka ovat
täällä päin Ranskan rajana. Siellä vilisee metsän riistaa, susia ja
karhuja, kauriita ja villisikoja. Olen kuullut kerrottavan, että suuri
Henrik-kuningas elämänsä loppuun asti rakasti tätä paikkakuntaa ja
vuosien ja valtiohuolten häntä painaessa ikävöitsi Béarnin eteläisiä
pyökkilehtoja ja puksipuun peittämiä ylänköjä. Auchin pengermäisiltä
rinteiltä näkee metsien aaltoilevan valossa ja varjossa, ylhäällä ja
alhaalla, lumihuippujen juurelle asti, ja vaikka olen syntyisin
Bretagnesta ja rakastan merituulten suolaisuutta, olen harvoin
tavannut näköaloja, jotka vetävät vertoja tälle.
Oli lokakuun toinen viikko, kun saavuin Cocheforêtiin eräänä

iltana, ratsastin pitkin viimeistä metsäharjua alas ja tulin avoimelle
paikalle kylään. Minä olin yksinäni ja olin ratsastanut koko päivän
punaisten pyökinlehtien hohteessa, hiljaisia metsäteitä, yli kirkkaiden
purojen ja vielä vihannoivien pikku tasankojen. Olin nähnyt
maaseudun rauhallista hiljaisuutta enemmän kuin oli sattunut
osakseni lapsuudestani saakka, ja sentähden tai mahdollisesti koska
minulla ei ollut mitään erityistä halua siihen tehtävään, joka oli
edessäni — nyt niin lähellä — tunsin mieltäni hiukan ahdistavan.
Suoraan sanoen en ollut tullut tälle seudulle mihinkään ritarilliseen
toimeen, katselinpa sitä miltä kannalta hyvänsä.
Mutta köyhän ei sovi kainostella, ja minä tiesin, ettei se mielentila

voinut olla pitkäaikainen. Majatalossa, muiden seurassa,
välttämättömyyden kannustamana tai ajon kiihoittamana, sittenkun
se oli alkanut, pääsisin siitä tunteesta kyllä eroon. Kun mies on nuori,
hakee hän yksinäisyyttä, mutta keski-ikäisenä hän karttaa sitä ja
ajatuksiaan, Ohjasin senvuoksi kulkuni »Vihreään pilariin», pieneen
kylänraitin varrella sijaitsevaan majataloon, johon minua oli neuvottu
Auchissa, koputin ratsuraippani perällä ja noiduin isäntää, joka antoi
minun odottaa.
Viheliäisten hökkelien ovilla kadun varrella, joka oli ahdas ja

likainen, tuskin ansaiten tätä nimeä, seisoi miehiä ja naisia
epäluuloisina tähystelemässä minua. Mutta en ollut heitä
huomaavinani, ja viimein tuli isäntäkin. Hän oli vaaleatukkainen
mies, puoleksi baski ja puoleksi ranskalainen, ja oli varmasti
tarkastellut minua huolellisesti jostakin ikkunasta tai tirkistysreiästä,
sillä ulos tullessaan hän ei näyttänyt vähääkään hämmästyneeltä
hyvinpuetun vieraan saapumisesta-— ihme näin syrjäisessä kylässä
—, vaan katseli minua juron umpimielisesti.
»Minä saan kai täällä nukkua yöni?» sanoin ja laskin ohjakset

raudikon kaulalle. Hevosen pää oli riipuksissa.
»En tiedä», vastasi hän, typerä ilme kasvoillaan.
Minä osoitin vihreään lehväkimppuun, joka törrötti seipään päässä

vastapäätä sisäänkäytävää. [Vanhastaan majatalon kyltti Ranskassa
ja Englannissa. Suom.]
»Eikö tämä ole majatalo?» kysyin minä.
»Kyllä», vastasi hän verkalleen, »majatalo on. Mutta…»
»Mutta teillä ei ole tilaa tai ruokaa tai on vaimonne sairaana taikka
jotakin muuta on vialla», keskeytin ärtyisesti. »Aion joka tapauksessa
maata täällä. Siihen teidän täytyy tyytyä, sekä itsenne että vaimonne
— jos teillä on sellainen.»
Hän raapi päätänsä ja katseli minua vastenmielinen ilme

silmissään.
Mutta hän ei hiiskunut mitään, ja minä laskeuduin satulasta.
»Mihin saan panna hevoseni suojaan?» kysyin.
»Minä vien sen talteen», vastasi hän nyreästi, astuen esille ja

ottaen ohjakset.
»Hyvä, mutta minä seuraan teitä. Kunnon ihminen on hyvä

hevoselleen, ja kaikkialla pidän aina huolta, että hevoseni saa
rehua.»
»Se saa rehua», vakuutti mies lyhyeen. Sitten hän odotti, että
menisin sisälle. »Vaimoni on sisällä», jatkoi hän ja katsoi minuun
itsepintaisesti.
»Imprimis — jos ymmärrätte latinaa, ystäväiseni», vastasin minä,

»hevonen talliin!»
Hän näki, ettei minua voinut saada hievahtamaankaan, käänsi

raudikon ja alkoi taluttaa sitä yli raitin. Majatalon takana oli vaja,
jonka olin jo huomannut ja otaksunut talliksi. Minua kummastutti
nähdessäni, että hän ei mennytkään sinne, mutta en tehnyt mitään
huomautusta, ja muutaman minuutin kuluttua näin hevoseni
kunnollisesti sijoitetuksi katokseen, joka näytti olevan jonkun
naapurin oma.
Kun se oli tehty, asteli mies takaisin majataloon, kantaen

tavaramyttyäni kädessään.
»Eikö teillä ole muita vieraita?» kysyin välinpitämättömän

näköisenä.
Tiesin hänen pitävän minua tarkoin silmällä.
»Ei.»
»Tätä kautta ei kai kuljekaan paljon matkustavaisia.»
»Ei.»
Se oli selväkin seikka, sillä tuskin olen koskaan nähnyt niin

syrjäistä paikkaa. Metsän peittämät harjut, jotka kohosivat jyrkkinä ja
melkoisen korkealle, sulkivat siinä määrin suojaansa laakson, etten
voinut käsittää, kuinka kukaan voisi tulla kylästä mitään muuta tietä
kuin mitä itse olin tullut. Talot olivat vain pieniä, matalia hökkeleitä
kaksinkertaisina säännöttöminä riveinä, joissa näkyi monta
ammottavaa aukkoa — siellä täällä kumoon kaatunut puu tai
huonosti hoidettu niittykaistale. Soriseva puro kiemurteli mökkien
välitse. Ja asukkaat, miilunpolttajia tai sikopaimenia taikka muita
jokseenkin samaan luokkaan kuuluvia köyhiä kituuttajia, eivät olleet
paremmassa kunnossa kuin heidän asumuksensakaan. Tähystelin
turhaan linnaa. Sitä ei näkynyt missään, enkä uskaltanut tiedustaa,
missä se sijaitsi.
Mies vei minut majatalon vierashuoneeseen, matalaan,

ränstyneeseen tupaan, jossa ei ollut uunia eikä lasiruutuja
ikkunoissa, — savusta ja liasta mustuneeseen. Takkavalkeana oli iso
puoleksi palanut halko kytemässä kiviliedellä, joka kohosi jalan
verran lattiasta. Korkea musta kattila porisi tulella, ja toisen ikkunan
ääressä istui muuan talonpoika jutellen emännän kanssa. En nähnyt
hänen kasvojaan hämärässä, mutta virkoin pari sanaa vaimolle ja
istuuduin odottamaan illallistani.
Hän näytti harvapuheisemmalta kuin hänen säätynsä naiset

tavallisesti, mutta se saattoi johtua siitä, että hänen miehensä oli
saapuvilla. Emännän astellessa edestakaisin illallistani laitellen
asettui mies ovenpieltä vasten ja alkoi tuijottaa minuun niin
itsepintaisesti, ettei minun ollut ollenkaan hyvä olla. Hän oli pitkä,
roteva mies. Viikset olivat kuin harjakset, ja ruskea parta oli leikattu
Henrik IV:n kuosiin; ja ainoastaan tästä kuninkaasta—
soveliaimmasta puheenaiheesta béarnilaisen kanssa — sain hänet
haastamaan. Silloinkin kuvastui hänen silmissään epäluuloinen ilme
varoittamassa, ettei minun sopinut tehdä mitään kysymyksiä. Kun
pimeys musteni hänen takanaan ja tuli valaisi yhä selvemmin hänen
kasvonsa ja kun ajattelin monen penikulman laajuisena Auchista
tähän etäiseen laaksoon leviävää korpea, muistuivat mieleeni
kardinaalin sanat, että jos onnistuisin huonosti yrityksessäni, en
luultavasti enää milloinkaan näkisi Pariisia.
Ikkunan ääressä istuva moukka ei kiinnittänyt minuun mitään

huomiota, enkä minäkään häneen, sittenkun olin kunnolleen
varmistautunut siitä, että hän todella oli miltä näytti. Mutta vähitellen
tuli tupaan pari kolme miestä — vantteria, karkeapintaisia roikaleita
— ja ne yhtyivät isännän seuraan; heilläkään ei näyttänyt olevan
muuta tekemistä kun istua äänettöminä tarkastelemassa minua, vain
silloin tällöin vaihtaen keskenään jonkun sanan omalla murteellaan.
Kun illallinen oli valmis, oli miehiä kerääntynyt kaikkiaan kuusi. He
olivat aseistettuja pitkillä espanjalaisilla väkipuukoilla, ja kun oli
päivänselvää, että he tylsällä, talonpoikaisella tavallaan olivat
närkästyneitä minun tulostani — kaikki talonpojathan ovat
epäluuloisia — aloin uskoa, että olin tietämättäni pistänyt pääni
ampiaispesään.
Söin ja join kuitenkin hyvällä halulla, mutta sauhuavan lampun

valopiirissä ei juuri mikään välttänyt huomiotani. Pidin silmällä
miesten katseita ja liikkeitä ainakin yhtä tarkoin kuin he minun, ja
koko ajan haudoin, millä tavoin haihduttaisin heidän epäluulonsa tai
tämän käydessä mahdottomaksi saisin hiukan enemmän tietää
asemasta, joka oli tuntuvasti pulmallisempi ja vaarallisempi kuin olin
osannut ajatella. Koko laakso näytti olevan varuillaan
puolustaakseen sitä miestä, jota tavoittelin.
Olin vartavasten tuonut mukanani Auchista pari pulloa hienoa

armagnacia, ja ne oli tuotu huoneeseen samalla kertaa kuin
satulareppunikin. Otin nyt esille yhden, avasin sen ja tarjosin
luontevasti ja huolettomasti isännälle kulauksen siitä. Hän otti
vastaan tarjoukseni. Hänen siematessaan huomasin, että hänen
kasvonsa punehtuivat. Vastahakoisesti hän antoi pikarin takaisin;
käsitin sen viittaukseksi ja täytin sen hänelle vielä kerran. Voimakas
juoma alkoi jo vaikuttaa; hän tyhjensi kolmannenkin pikarillisen ja
puheli muutaman minuutin kuluttua vapaammin ja vähemmän
väkinäisesti kuin oli ennen ollut meidän kaikkien sävynä. Hän teki
olletikin paljon kysymyksiä — halusi tietää sitä ja saada selville tätä
— mutta sekin oli mieluisa muutos. Kerroin hänelle vilpittömästi,
mistä olin tullut, mitä tietä, kuinka kauan olin ollut Auchissa ja missä
siellä; niin pitkälle tyydytin hänen uteliaisuuttansa. Mutta kun tuli
kysymykseen, mitä tarkoitti käyntini Cocheforêtissa, olin
salaperäisen vaitelias, viittailin hämärästi Espanjan asioihin ja
rajantakaisiin ystäviin j.n.e.; siten saattoivat talonpojat, jos halusivat,
tehdä sen johtopäätöksen, että minäkin kuuluin samaan
puolueeseen kuin heidän maanpakoon tuomittu herransa.
He tarttuivat koukkuun, iskivät silmää keskenään ja alkoivat

katsella minua leppeämmin — etenkin isäntä. Mutta niin pitkälle
päästyäni en uskaltanut mennä pitemmälle, jotten olisi johtunut
mihinkään varomattomuuteen ja mahdollisesti antanut itseäni ilmi.
Keskeytin sentähden ja siirryin ylimalkaisempiin puheenaineisiin,
tehden vertailua oman kotiseutuni ja heidän maakuntansa välillä.
Isäntä oli nyt käynyt aika puheliaaksi eikä ollut hidas innostumaan, ja
se haastelu johti siihen, että sain hyvin merkillisen tiedon. Hän
kerskui korkeista lumivuoristaan, niitä peittävistä metsistä ja näissä
samoavista karhuista, vuorikauriista, jotka niin hyvin viihtyivät
ylhäällä jäätiköillä, ja villisioista, jotka elivät tammenterhoista.
»No niin», sanoin minä kuin sivumennen, »sellaisia meillä ei ole,

sen myönnän. Mutta meillä on pohjoisessa muuta, mitä teillä ei ole.
Meillä on kymmenin tuhansin muhkeita hevosia — ei sellaisia
pienokaisia kuin te täällä kasvatatte. Fécampin hevosmarkkinoilla ei
minun raudikkoani edes huomattaisi joukosta. Täällä etelässä ei
tapaa sen vertaista kokonaisen päivän matkalla.»
»Älkää olko liian varma siitä», vastasi mies, ja hänen silmänsä

loistivat voitonriemusta ja viinin vaikutuksesta. »Mitä sanoisitte, jos
näyttäisin teille vielä paremman — omassa tallissani?»
Näin hänen sanojensa säikähdyttävän muita kuuntelijoita, ja ne

heistä, jotka ymmärsivät meitä — kaksi tai kolme puhui ainoastaan
omaa mongerrustaan — loivat häneen vihastuneita silmäyksiä.
Vilauksessa aloin ymmärtää asian, mutta tekeydyin typerän
näköiseksi ja nauroin halveksivasti.
»Sitä en usko ennen kuin näen», sanoin. »Epäilen, ystäväiseni,

että osaatte erottaa hyvää hevosta huonosta, nähdessänne ne.»
»Enkö osaa?» sanoi hän räpyttäen silmiään. »Vai niin, vai en?»
»Epäilen sitä», sanoin minä itsepintaisesti.
»Seuratkaa minua sitten, niin näytän teille sellaisen», vastasi hän,

sillä itserakkaus voitti nyt vaiteliaisuuden. Huomasin hänen
vaimonsa ja muiden katselevan häntä kauhistuneina, mutta heistä
piittaamatta hän nousi, otti lyhdyn ja avasi oven. »Tulkaa mukaan»,
sanoi hän voitonvarmalla äänellä. »Vai niin, minäkö en osaa
arvostella hyvää hevosta, kun näen sen? Tunnen ainakin yhden,
joka on parempi kuin teidän!»
En olisi ihmetellyt, jos muut miehet olisivat astuneet väliin, mutta

sitä he eivät tehneet; hänellä näytti olevan heistä suurin sananvalta,
ja tuossa tuokiossa olimme ulkona. Kolme askelta edettyämme
pimeässä olimme tallin edessä; se oli majatalon takana. Isäntä nosti
säpin, meni edellä ja kohotti lyhtyä. Hevonen hirnui hiljaa ja käänsi
kirkkaat, lempeät silmänsä meihin — se oli kastanjanruskea juoksija,
ja sillä oli valkopilkkuinen häntä ja valkoiset jalat.
»Katsokaa!» huudahti saattajani ja liikutti lyhtyä pöyhkeilevästi

ylös ja alas, jotta näkisin ratsun oikein tarkoin. »Mitä sanotte! Onko
tämä 'pienokainen'?»
»Ei», vastasin minä, tahallani säästellen kehumista, »se on varsin

komea — tälle seudulle.»
»Tai mille seudulle hyvänsä», tokaisi hän suuttuneesti. »Mille

seudulle hyvänsä, sen sanon — missä tahansa! Eikä se ole
ihmekään, sillä hevosen om… niin, se on komea hevonen; jos ette
milloinkaan ole nähnyt uhkeata hevosta, niin nyt näette!» Ja siihen
hän keskeytti lörpötyksensä ihan äkkiä, antoi lyhdyn vaipua nopealla
liikkeellä ja kääntyi ovea kohden. Nyt hänellä oli niin kiire päästä pois
sieltä, että melkein tyrkkäsi minut ulos.
Mutta minä ymmärsin. Minä tiesin, että hän oli ollut vähällä
ilmaista kaikki ja lavertaa, että hevonen oli de Cocheforêtin,
comprenez bien! Minä käännyin pimeään, jottei hän olisi nähnyt
hymyäni, enkä sitten laisinkaan kummeksunut, että mies oli
silmänräpäyksessä kerrassaan muuttunut. Oven suljettuaan hän oli
yhtä selvä ja epäluuloinen kuin ennenkin; hän häpesi ja oli
raivoissaan minulle. Hän oli sellaisessa mielentilassa, että olisi
voinut katkaista kurkkuni pienimmästäkin aiheesta.
Ei kuitenkaan kuulunut suunnitelmaani riidan haastaminen.

Sentähden tekeydyin ymmärtämättömäksi kaikesta, ja kun tulimme
takaisin majataloon, ylistin ratsua nyreästi, ikäänkuin olisin ollut vain
puolittain vakuutettu väitteeni häviöstä. Ne ilkeät katseet ja uhkaavat
aseet, joita näin ympärilläni, kehoittivat minua varovaisuuteen, eikä
yksikään italialainen olisi voinut näytellä osaansa taitavammin kuin
minä tein — sillä voin imarrella itseäni. Mutta olin sydämestäni
iloinen, kun pääsin rauhaan ja vihdoinkin olin yksinäni yösijallani
pienessä kammiossa, joka oli tuskin kanakoppia isompi; se sijaitsi
yläkerrassa katon ja päätyseinän soppena, ja seinillä riippui omena-
ja kastanjakimppuja.
Se oli vaatimaton makuuhuone, ränstynyt, kylmä ja siivoton.

Kapusin sinne tikkaita myöten; vuoteenani oli kasa saniaisia ja oma
viittani. Mutta hyvilläni olin päästessäni sinne, sillä siellä sain olla
yksin ja häiritsemättä miettiä asemaani.
Herra de Cocheforêt oli luonnollisestikin linnassa.
Hän oli jättänyt hevosensa tänne ja kävellyt perille jalkaisin; se oli

luultavasti hänen tavallinen menettelytapansa. Hän oli siis tavallaan
minun ulottuvissani — en olisi voinut saapua sinne otollisempaan
aikaan — mutta toiselta puolen hän oli yhtä vähän vallassani kuin jos
olisin vielä ollut Pariisissa. Sillä niin kykenemätön olin vangitsemaan
häntä, ette edes uskaltanut mitään kysyä tai virkkaa ajattelematonta
sanaa tai edes katsella vapaasti ympärilleni. Sitä en uskaltanut, sen
oivalsin aivan hyvin. Pieninkin viittaus asiaani, vähäisinkin epäluulon
varjo olisi aiheuttanut väkivaltaisuuksia, jotka olisivat käyneet yli
voimieni; ja mitä kauemmin viivyin kylässä, sitä enemmän herättäisin
epäluuloa, ja sitä tarkemmin minua vartioitaisiin.
Sellaisessa tilanteessa olisivat useimmat jättäneet epätoivoisina

yrityksen sikseen ja karanneet yli rajan. Mutta minä olen aina pitänyt
kunnia-asianani uskollisuutta enkä vetäytynyt takaisin. Jos ei tänään,
niin huomenna; jos ei tällä, niin seuraavalla kerralla. Arpanopat eivät
aina putoa toivomuksen mukaan. Minä mukaannuin senvuoksi
olosuhteisiin, ja niin pian kuin talossa oli hiljaista, ryömin ikkunan
eteen, pienelle nelikulmaiselle avoimelle luukulle, joka oli
hämähäkinverkkojen peittämä ja osaksi heinillä tukittu. Kurkistin
ulos. Kylä näytti nukkuvan. Puiden tummia oksia riippui vähän
matkan päähän luukusta, melkein pimittäen harmaan, pilvisen
taivaan, jonka laella kelmeä kuu kolkosti leijaili. Tähystäessäni alas
en aluksi voinut nähdä mitään, mutta kun silmäni tottuivat pimeään
— olin sammuttanut kynttiläpahaseni — erotin tallin oven ja
ulkorakennuksen katon tummat reunapiirteet.
Juuri sitä olin toivonut, sillä nyt saatoin pitää silmällä ja ainakin
saada selville, poistuiko Cocheforêt ennen aamua. Jollei hän lähtisi
pois, niin aioin hankkia tilaisuuden nähdä hänen kasvonsa ja kenties
saada tietooni muita seikkoja, joista minulle saattoi vastedes olla
hyötyä.
Koetin tottua epämukavuuteen, istuuduin lattialle luukun ääreen ja

aloitin vartioimiseni, jota tiesin voivan kestää aamuun asti. Kului
tunti, mutta jo silloin kuulin kuiskeita alhaalta, sitten askeleita;
joitakuita henkilöitä kääntyi kulmasta, ja muuan ääni puhui kovaa ja
rohkeasti. En voinut erottaa sanoja enkä ymmärtää niiden
tarkoitusta, mutta ääni oli aatelismiehen, ja sen rivakka ja käskevä
sävy sai minut heti vakuutetuksi siitä, että siellä oli herra de
Cocheforêt itse. Toivoen saavani tietää enemmän painoin kasvoni
lähemmäksi aukkoa ja olin juuri onnistunut erottamaan kaksi olentoa
hämyssä — toinen oli pitkä, hoikka mies levättiin kääriytyneenä,
toinen otaksuakseni nainen, valkoinen puku yllä — kun raju koputus
kammioni ovelta sai minut heittäytymään taaksepäin luukulta ja
nopeasti paneutumaan vuoteeseeni. Koputus uudistui.
»No!» huudahdin minä, kohottautuen kyynäspääni varaan
vuoteellani ja noituen kiusallista keskeytystä. Teki julmasti mieleni
nähdä enemmän. »Mikä nyt? Mikä on hätänä?»
Ullakkoluukku aukeni jalan verran tai enemmänkin. Isäntä pisti

päänsä sisälle.
»Te huusitte, vai mitä?» kysyi hän.
Hän piteli talikynttilän pätkää, joka valaisi puolet huonetta ja hänen

virnistelevät kasvonsa.
»Huusinko — tähän aikaan yöstä, tomppeli?» vastasin

suuttuneena. »En huutanut. Menkää maata!»
Mutta hän seisoi yhä tikkailla typerästi töllistellen.
»Kuulinhan minä teidän huutavan», intti hän.
»Menkää nukkumaan! Olette juovuksissa», vastasin minä ja

nousin istumaan. »En ole huutanut, sen vakuutan.»
»Vai niin, vai ette», vastasi hän verkalleen. »Ja ettekö halua
mitään?»
»En mitään — kunhan vain saan olla rauhassa», vastasin

kiukkuisena.
»Hm… Hyvää yötä sitten!»
»Hyvää yötä, hyvää yötä!» vastasin minä niin kärsivällisesti kuin

voin. Samassa kuulin tavallista talutettavan hevosen tömistelyä.
»Hyvää yötä!» kertasin innokkaasti, toivoen hänen vetäytyvän pois
siksi ajoissa, että ehtisin tirkistää ulos. »Tahdon nukkua.»
»Hyvä», sanoi hän leveästi irvistäen. »Mutta nyt on vielä varhaista,
ja teillä on hyvää aikaa.»
Viimein hän veti ullakkoluukun kiinni, ja sitten kuulin hänen

hihittävän tikkaita alas mennessään.
Ennen kuin hän oli päässyt ihan alas, olin taas ikkunaluukulla.
Nainen, jonka olin nähnyt, viipyi vielä samassa paikassa, ja hänen
vieressään seisoi mies, joka oli puettu talonpojan asuun ja piteli
lyhtyä. Mutta se mies, jonka olisin mieluimmin nähnyt, ei ollut siellä.
Hän oli mennyt, ja selvää oli, etteivät toiset enää pelänneet minua,
sillä tähystellessäni alas tuli isäntä heidän luokseen, hänkin lyhty
kädessään ja sanoi jotakin naiselle, jolloin tämä katsoi ylös ikkunaani
ja nauroi.
Oli lämmin yö, eikä hänellä ollut mitään päällysnuttua valkoisen

pukunsa yllä. Minä näin hänen solakan, kauniin vartalonsa ja
loistavat silmänsä sekä kauniiden kasvojen lujatahtoiset piirteet, joita
mahdollisesti voisi sanoa liian säännöllisiksi, jos niissä mitään
virhettä oli.
Odotin, kunnes ryhmä hajaantui ja nainen talonpoikaisen miehen

keralla kääntyi majatalon nurkan taakse, häviten näkyvistäni. Sitten
laskeuduin takaisin vuoteelleni, entistä epätietoisempana, miten
minun tulisi menetellä. Oli selvää, että onnistuakseni minun täytyi
hankkia pääsy linnaan, jonka väkenä, mikäli olin kuullut ennen
lähtöäni, oli ainoastaan kaksi tai kolme vanhaa miespalvelijaa ja yhtä
monta palvelijatarta, koskapa madame, linnan rouva, paremmin
pitääkseen salassa miehensä vierailuja vietti ja oli tehnyt tietyksi
viettävänsä hyvin eristettyä elämää. Hänen miehensä vangitseminen
kotonaan ei siis ollut mikään mahdoton tehtävä; täällä sitä vastoin,
keskellä kylää, olisi joukko ratsuväkeäkin helposti voinut hävitä
yrityksessä.
Mutta kuinka voisin tunkeutua taloon, jota viekkaat naiset

vartioitsivat ja kaikki varokeinot saarsivat, mitä rakkaus voi keksiä?
Siinä oli kysymys, ja vielä päivän valjetessa mietiskelin sitä ja olin
yhtä kaukana ratkaisusta kuin ennenkin. Huolissani kun olin, tulin
oikein iloiseksi, kun aamu koitti, jotta pääsin nousemaan makuulta.
Ajattelin raikkaan ilman voivan elvyttää kekseliäisyyttäni ja olin
kyllästynyt ummehtuneeseen kojuuni. Hiivin hiljaa alas tikkaita ja
pääsin huomaamattomana livahtamaan läpi alakerran huoneen,
jossa monta henkilöä makasi kuorsaten. Ulko-ovi ei ollut lukossa, ja
pian olin ulkona tiellä.
Oli vielä niin varhaista, että puut kohosivat tummina varjoina

rusottavaa taivasta vasten, mutta seipään päässä oven ulkopuolella
loisti lehväkimppu vihreänä ja tiesin harmaan aamuvalon tulvivan
hetken kuluttua kaikkialle. Se levitti jo kumotustaan tielle, ja
seistessäni nurkalla — mistä näin sekä talon etupuolelle että tallin
taholle — ja hengittäessäni raitista ilmaa, etsien yöllisen
matkaanlähdön jälkiä, huomasin jonkin vaalean esineen maassa. Se
oli vain parin askeleen päässä minusta, ja heti astuin ottamaan sen,
toivoen saavani siepatuksi kirjeen. Mutta se ei ollut kirje, vaan ohut
vaaleankeltainen maustekotelo, jollaista naiset kantavat povellaan,
Se oli täytetty heikosti tuoksuvalla jauheella, ja kylkeen oli E-kirjain
ommeltu valkoisella silkillä; se oli tuollainen pieni ja siro
ylellisyysesine, josta naiset pitävät.
Rouva de Cocheforêt oli kai pudottanut sen yöllä. Kääntelin sitä

käsissäni ja pistin sen sitten hymyillen taskuuni; siitä saattoi olla
joskus minulle jotakin hyötyä. Tuskin olin sen tehnyt ja kääntynyt
katselemaan ylöspäin tietä, kun ovi narisi takanani saranoillaan tai
oikeammin sanoen nahkahihnoillaan, ja samassa seisoi isäntä ihan
takanani, tervehtien minua happamesti. Hänen epäluulonsa olivat
ilmeisesti taas heränneet, sillä siitä hetkestä saakka hän sovitti niin,
että hän verukkeella tai toisella oli seurassani päivälliseen asti.
Hänen sävynsä kävi sitäpaitsi yhä yrmeämmäksi ja hänen
viittauksensa yhä selvemmiksi, jotten voinut enää pitemmälle
tekeytyä ymmärtämättömäksi. Päivällisen aikaan kun hän jo ainakin
kahdennenkymmenennen kerran seurasi minua ulos tielle, hän kävi
suoraan käsiksi asiaan ja kysyi minulta äreästi, enkö jo tahtonut
hevostani.
»En», sanoin minä. »Miksi sitä kysytte?»
»Sentähden», vastasi hän ilkeästi hymyillen, »että tämä ei ole

terveellinen paikka vieraille.»
»Vai niin», huomautin minä. »Mutta, katsokaas, minä pidän raja-

ilmasta.»
Se oli sopiva vastaus, sillä eilisiltaisiin puheisiini liittyvänä se tuotti

hänelle päänvaivaa vihjaamalla, että minäkin kuuluin ahdistettuihin ja
että minulla oli omat syyni pysytellä Espanjan rajalla. Ennenkuin hän
oli lakannut vaivaamasta aivojansa tällä pulmalla, keskeytti kylätien
uneliaan hiljaisuuden kavioiden kopse, ja nainen, jonka olin nähnyt
yöllä, ratsasti nopeasti esille nurkan takaa ja pysäytti juoksijansa.
Minuun katsahtamatta hän huusi majatalon isäntää tulemaan
luokseen.
Isäntä meni. Hänen käännettyään minulle selkänsä hiivin sieltä

pois ja seuraavassa hetkessä olin erään talon takana suojassa.
Kaksi tai kolme renttumaista olentoa tuijotti minuun, mutta kukaan ei

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Nuclear Cardiology: Practical

Applications, 4th Edition - eBook PDF

FM.indd 1 17-02-2022 12:14:09

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Gary V. Heller, MD, PhD, MASNC, FACC

Robert C. Hendel, MD, MACC, MASNC, FAHA, FSCCT

New York Chicago San Francisco Athens London Madrid Mexico City

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eBook conversion by codeMantra

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Contributors.. . . . . . . . . . . . . . . . . . . . . . . . . . . ix 9. SPECT Myocardial Perfusion

6. Radiation Exposure and Reduction 15. Clinical Applications of Quantitation

7. Physician Certification and Laboratory 16. Appropriate Use of Nuclear Cardiology

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19. Risk Stratification with Myocardial 24. Radionuclide Imaging of Cardiac

20. Nuclear Cardiovascular Imaging 25. Imaging Cardiac Amyloidosis���������� 479

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Parthiban Arumugam, MD Sharmila Dorbala, MD, MPH, FACC, MASNC

FM.indd 9 17-02-2022 12:14:09

James R. Galt, PhD Matthew J. Memmott, MSc

Saurabh Malhotra, MD, MPH, FACC, FASNC Gautam V. Ramani, MD

FM.indd 10 17-02-2022 12:14:09

Archana Ramireddy Joey Stevens, CNMT

Dillenia Rosica, MD E. Lindsey Tauxe, MEd, CNMT, FASNC

Rupa M. Sanghani, MD, FACC, FASNC Jason S. Tavel, PhD, DABR

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sec01.indd 1 15-02-2022 12:34:58

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C. David Cooke, James R. Galt and E. Lindsey Tauxe

ch01.indd 3 15-02-2022 09:36:29

▶▶Electron Configuration K = quantum #1 = 2(1)2 = 2 electrons

ch01.indd 4 15-02-2022 09:36:32

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Line of stability and dosimetry perspectives, due to their lower prob-

ch01.indd 6 15-02-2022 09:37:33

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yield, in ratio to γ-photon yield, is specific to a given

ch01.indd 8 15-02-2022 09:37:46

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Since ln 2 is equal to 0.693, we have: INTERACTIONS OF RADIATION

ch01.indd 10 15-02-2022 09:38:38

as the Z number of the matter. A highly charged mas-

ch01.indd 11 15-02-2022 09:38:38

ch01.indd 12 15-02-2022 09:38:39

▶▶Attenuation thickness (HVT) or half-value layer (HVL). The

ch01.indd 13 15-02-2022 09:38:52

from 99mTc and 201Tl, respectively. The emissions used REFERENCES

ch01.indd 14 15-02-2022 09:38:52

ch02.indd 15 15-02-2022 16:37:19

guidance specific to radioactive materials licensing Table 2-1

ch02.indd 16 15-02-2022 16:37:19

SOURCES OF RADIATION EXPOSURE IN THE UNITED STATES

Consumer Products Industrial and Occupational

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RELEASE OF PATIENTS ADMINISTERED

FIGURE 2-2 Stochastic and deterministic effects from

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20. Nuclear Cardiovascular Imaging 25. Imaging Cardiac Amyloidosis�� 479