MPI

Nuclear Cardiac Imaging (Myocardial

Perfusion Imaging)

• Myocardial Perfusion Imaging (MPI) – What is it?

• MPI Images – What does it look like?
• Clinical Value – What good is it?
• How to interpret MPI?
• Comparison with other modalities
• – Why MPI?
What is Myocardial Perfusion Imaging?

 In the U.S., nuclear cardiology (MPI) procedures have overtaken non-

cardiology procedures in procedural volume.
20,000
18,000
16,000
Procedures (thousands)

14,000
12,000
10,000
8,000
6,000
4,000
2,000
-
1994 1995 1996 1997 1998 1999 2000 2001 2002

Non-cardiology Cardiology Total

 What is Myocardial Perfusion
Imaging?
MPI is a non-invasive nuclear imaging
technique that uses radioactive imaging
agents to image the heart.
Thallium - 201
Technetium-99 m Sestamibi
Technetium-99 m Tetrofosmin
 Patient preparation

• Nothing orally (expect oral medication or water).

• Comfortable clothing for the exercise portion of the exam.
• Medications that contain methylxanthines or caffeine and
food beverage with caffeine must be avoided for 12-24 hours
if vasodilator stress test is anticipated.
• Metal or other potential attenuators must be removed if they
project on the imaging field so as to avoid attenuation
artifacts.
• For primary diagnosis of CAD, certain cardiac medication such
as nitroglycerine or β-blockers must be avoided to increase
the sensitivity
 Myocardial Perfusion
Performed at rest & stress

Stress study options

treadmill exercise
pharmacologic stress agents
adenosine
persantine (dipyridamole)
dobutamine
 Exercise Protocol
• Exercise preferred modality
• Radiopharmaceutical injected at peak and
continued exercise for another 1-2 minutes.
• If unable to exercise, unable to attain target
heart rate, or contraindications pharmacologic
testing should be performed.
• B-blockers should be held for 48 hours
• No caffeine for 24 hours.
 Exercise Testing- Contra Indications
• Unstable Angina
• Decompensated CHF
• Uncontrolled hypertension (blood pressure >
200/115 mm of Hg)
• Acute myocardial infarction within last 2 to 3
days
• Severe pulmonary hypertension
• Relative contraindication AS, HCM
 Exercise Testing
• Each of the protocols has advantages and
disadvantages.
• Quality control from preparation, acquisition
to reading assure the best data.
PHARMACOLOGIC VASODILATOR STRESS
• There are currently three vasodilator agents
available:
1. Dipyridamole
2. adenosine
3. regadenoson
• stimulates A2A receptors
 Dipyridamole
(Persantine)
• Dipyridamole is a coronary artery vasodilator that increases the tissue levels of
adenosine by preventing the intracellular reuptake and deamination of
adenosine. Dipyridamole induced hyperemia lasts for more than 15 minutes.
• Dose: Dipyridamole is administered at 0.56 mg/kg intravenously over a 4-
minute period (142 mcg/kg/min).
• Side Effects. flushing, chest pain, headache, dizziness, or hypotension. The
frequency of these side effects is less than that seen with adenosine .
• Aminophylline (125-250 mg intravenously) is often required to reverse these
side effects.
• Aminophylline should also be used in the presence of ischemic ECG changes.
• Hemodynamic Effects.
• Dipyridamole results in similar hemodynamic changes as seen with adenosine
with a modest increase in heart rate and a modest decrease in both systolic
and diastolic blood pressures.
 Contraindications
1. Asthmatic patients with ongoing wheezing should not undergo
adenosine stress testing.
2. Second- or third-degree AV block
3. Systolic blood pressure <90 mm Hg.
4. Methyl xanthines such as aminophylline caffeine or theobromine block
the effect of adenosine and should be held for at least 12 hours prior to
the test
5. Known hypersensitivity to adenosine.
6. Unstable acute myocardial infarction or acute coronary syndrome.
 Myocardial Perfusion Scintigraphy:
Assessment of Diagnosis, Prognosis, and
Treatment Response of Cardiovascular Risk.

Diagnosis, Prognosis, and Response to

Therapy
• Suspected Coronary artery disease
• Known stable coronary artery disease
• Prior to non-cardiac surgery
• Before and after cardiac revascularization
Myocardial PerfusionScintigraphy: Assessment of Diagnosis,
Prognosis, and Treatment Response of Cardiovascular Risk

Diagnosis, Prognosis, and Response to

Therapy Special populations (women,
diabetics)
• Evaluation of acute chest pain syndromes
• Myocardial infarction
• Screening: Multiple risk factors, Family
history
• Response to medical therapy
 Populations Who Benefit from SPECT MPI
• Diagnostic and prognostic chest pain evaluation
• Angina
• Atypical Angina
• Atypical Chest Pain
• Non-cardiac Chest Pain
• Peri-operative risk of non-cardiac surgery
• Diagnostic and prognostic evaluation of ACS
• Emergency Department
• In Hospital
 Populations Who Benefit from SPECT MPI

• Hemodynamic/prognostic assessment of known CAD

• High risk asymptomatic populatios
• Diabetes, Metabolic syndrome, insulin resistance syndrome
• Family history of sibling with coronary event
• Mediastinal radiation
• Multiple coronary risk factor
• Monitoring effectiveness of surgical and percutaneous
revascularization
• Monitoring effectiveness of “ medical revascularization”
 What do MPI images look like?
• In a typical
nuclear cardiac
imaging exam, the
physician reviews:
– Static “Summed
Perfusion Images”
– Dynamic “Gated
Images”

Perfusion Images are viewed in three orientations:

SA – Short Axis
VLA – Vertical Long Axis
HLA - Horizontal Long Axis
 What do MPI images look like? -
Summed Perfusion Images
• Summed images are used to assess cardiac perfusion. Rest and Stress
images are compared to determine if a region of the heart is “ischemic” –
starved of oxygen

• In the study below, the rest image indicates normal blood flow, but the stress
image indicates abnormal blood flow in the Inferior-lateral region.

Stress

Rest

• This may indicate “ischemia” in this region of the heart – which is supplied by
the LCX (left circumflex artery). There may be stenosis in that coronary artery.
What do MPI images look like? - Summed
Perfusion Images
Stress
SA
Rest

Stress
SA
Rest

Stress
VLA
Rest

Stress
HLA
Rest
 What do MPI images look like?
Gated Images

• Gated images are made

possible by ECG-gated
SPECT
SA
• Physicians can now
access cardiac function:

• Wall motion – does the LV

contract uniformly?
HLA • Ejection Fraction – does
the LV pump out enough
blood to the body?
VLA
Normal Myocardial Perfusion
Myocardial Ischemia
 Exam Results
Myocardial Infarction
perfusion defect on rest & stress

Myocardial Ischemia
perfusion defect on stress only
Myocardial Infarction
 How to read summed MPI Images
• Perfusion defect (In stress or rest or in both)
i.e. either ischemia or infarct
• LV Cavity size or LV dilatation in stress or both in
stress and rest
• RV uptake
• Lung uptake
• Artifacts (gut uptake, breast, motion defects)
• How to calculate % of myocardium at risk of
ischemia or infarcted
Coronary Distribution (Left Ventricle)
 What Good is MPI? – Clinical Value
• A nuclear stress test provides excellent negative predictive value
- Patients from the general population with normal MPI scans have <1%
annual risk of cardiac events
 Value of Stress MPI in the general
population: Stress MPI: Prognostic
Significance
Nonfatal MI/Cardiac Death Rate Per Year ( Percent)

8
7
6
5 Nonfatal MI/Cardiac
4 Death Rate Per Year (
3 Percent)
2
1
0
Normal Abnormal
What Good is MPI? – Clinical Value
• A gated nuclear stress test is a powerful tool to risk stratify patients for
optimal management.
• It is in effect a “gate-keeper” to the cardiac cath lab
Incremental value Of SPECT