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jeffrey kempf md gabrielle lacroix rn ccrn n.
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Evaluating Cardiovascular Diseases with Cardiac SPECT and PET PowerPoint Presentation
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Evaluating Cardiovascular Diseases with Cardiac SPECT and PET

Evaluating Cardiovascular Diseases with Cardiac SPECT and PET

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Evaluating Cardiovascular Diseases with Cardiac SPECT and PET

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  1. Jeffrey Kempf, MD Gabrielle LaCroix, RN, CCRN Evaluating Cardiovascular Diseases with Cardiac SPECT and PET

  2. Nuclear Cardiac Stress Testing

  3. Stress Test Options • ETT (EST / Regular) Bruce protocol • ETT with Myocardial Perfusion Imaging(TST) • Pharmacological Stress • Dipyridamole (Persantine ) • Adenosine • Dobutamine Stress ECHO: Exercise Dobutamine

  4. ACC/AHAExercise Guidelines • ACC/AHA statistics 1:2500 can experience MI or death. • Perform only with appropriate indications and considerations • Requires supervision by trained physician or individual who meets ACC/AHA competency guidelines

  5. Exercise Stress Test • Indications • Diagnose suspected CAD in patients with chest pain(atypical /typical) and normal EKG • Assess long term-risk in patients thought to be at intermediate /high risk for significant CAD • Evaluate suspected arrhythmias • Assess functional ability • Evaluate effectiveness of medical/surgical therapy

  6. Absolute Contraindications • Recent AMI (within 48 hrs)-RWJUH 4 days • Unstable Angina • Uncontrolled arrhythmias • Severe symptomatic aortic stenosis • Uncontrolled symptomatic CHF • Acute pulm embolus/pulm infarction • Acute aortic dissection/aneurysm • Uncontrolled HTN

  7. Relative Contraindications • Left main disease • Mod stenotic valve disease • Electrolyte abnormalities • Severe arterial HTN (sys BP>200mm Hg, dias >110mm Hg) • Tachy/Brady arrhythmias • HCM or LVOT obstruction • Acute DVT • CVA within 3 months • Inability to adequately exercise • Acute systemic illness (pneumonia, severe anemia, infections)

  8. EKG Exclusion Criteria Resting EKG abnormalities which render interpretation inconclusive and nuclear stress would be indicated. • Baseline ST segment depressions > 1mm • Digoxin • WPW • Left Bundle Branch Block • PPM • EKG criteria for LVH

  9. Exercise Procedure(Bruce Protocol) • Goal 220-age= 100% MPHR, need 85% for diagnostic study. • Low-level or Modified Bruce: Goal 75% MPHR or symptom limited. • NPO for 3 hours • Must be able to walk treadmill • Notify if ICD present • No smoking ( no nicotine patches) • Hold beta blockers, nitrates (check with MD) • Comfortable clothing/shoes

  10. Bruce Protocol

  11. Indications for termination of test Absolute • Drop in sys BP of >10mm Hg from pre-test standing BP despite increase in workload with ischemic evidence • Moderate to severe angina • Sustained VT • ST elevation > 1mm in leads without diagnostic Q waves • Subjects desire to stop • Dizziness, near syncope, ataxia • Technical difficulties with EKG/BP • Signs of poor perfusion (pallor, cyanosis)

  12. Relative • Drop systolic BP > 10mm Hg despite increase workload without evidence of ischemia • ST depression ≥ 2mm horizontal/downsloping • Arrhythmias: multifocal PVC’s, triplets, tachy/brady arrhythmias • Fatigue, leg cramps, SOB, wheezing • New BBB or IVCD • HTN: sys > 250mm Hg, dias >115mm Hg

  13. ST Depression -Represents subendocardial ischemia -Abnormal >1mm horizontal/downsloping at .08sec past “J” point.

  14. Case: 48yr M R/O ACS 100%MPHR/10 min Rest EKG Peak Exercise

  15. Myocardial Perfusion ImagingSPECT • Indications • Detects presence/location/extent of myocardial ischemia in patients with R/O ACS • Risk stratification after ACS • Identify fixed defects, evaluate EF and viability • CP with abnl EKG’s (LBBB, PPM, LVH, NSSTW changes) • Equivocal ETT • Inability to exercise (pharmacological stress)

  16. MPI Radiopharmaceuticals • Thallium 201 • Technetium–99m • Sestamibi (Cardiolyte) • Tetrafosmin (Myoview) • Dual Isotope • Thallium injected for resting images • Tech -99m injected at peak stress • Resting Thallium -utilized to assess viability(no stress)

  17. ThalliumMPI Prep MI ruled out by cardiac markers NPO 6-12 hrs, NO CAFFEINE 24 hrs Wgt. <350 lbs. Consent IV access (peripheral preferred) No nuclear scans 24 hrs.(V/Q, bone) Be able to lie flat with hands behind head for 15 mins. x 2 Must be able to walk treadmill Notify if ICD present Pregnancy test for premenopausal women

  18. PHARMACOLOGICAL MPI • Indications: inability to exercise, abnl EKG (LBBB, PPM/ICD), risk stratification • Dipyridamole(Persantine)-indirectly causes coronary dilatation by blocking adenosine receptor sites. • Infused over 4 min, isotope at 7-9 min or hemodynamic response • Adenosine- potent vasodilator • Infused over 4 min, isotope at 2 min • Low level exercise diminishes side effects

  19. CONTRAINDICATIONS • Asthma/Severe COPD (can induce bronchospasm) • Hypotension • Recent CVA (within 30 days) • NY HA Class IV CHF SIDE EFFECTS • Chest Pain • Headache • Flushing • Nausea • Transient asystole & heart block(Adenosine)

  20. Dipyridamole/Adenosine prep • NPO 12 hours (No Caffeine for 24 hrs) • No methylxanthines(bronchodilators) • Actual wgt. (drugs are wgt. based!) • Systolic BP>95mm Hg • No oral dipyridamole • Hold beta blockers • Use with caution: migraines

  21. DOBUTAMINE • + Inotropic effect, increases myocardial O2 demand • Prep: same as ETT (no beta blockers, ICD off, etc) • Infuse 5-40 mcg/kg/min over 15 min • Goal to achieve 85% MPHR (atropine given 35% time) • End points same as ETT( EKG changes, CP, HTN etc.) SIDE EFFECTS • HTN • Chest pain • Arrhythmias(PVC’s 15%, SVT/Atrial 8%, NSVT 4%) • Palpitations/Anxiety

  22. SPECT MYOCARDIAL IMAGES