jeffrey kempf md gabrielle lacroix rn ccrn
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Evaluating Cardiovascular Diseases with Cardiac SPECT and PET

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Jeffrey Kempf, MD Gabrielle LaCroix, RN, CCRN. Evaluating Cardiovascular Diseases with Cardiac SPECT and PET. Nuclear Cardiac Stress Testing. Stress Test Options. ETT (EST / Regular) Bruce protocol ETT with Myocardial Perfusion Imaging(TST) Pharmacological Stress Dipyridamole (Persantine )

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stress test options
Stress Test Options
  • ETT (EST / Regular) Bruce protocol
  • ETT with Myocardial Perfusion Imaging(TST)
  • Pharmacological Stress
    • Dipyridamole (Persantine )
    • Adenosine
    • Dobutamine

Stress ECHO: Exercise


acc aha exercise guidelines
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
exercise stress test
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
absolute contraindications
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
relative contraindications
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)
ekg exclusion criteria
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
exercise procedure bruce protocol
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
indications for termination of test
Indications for termination of test


  • 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)
  • 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
ST Depression -Represents subendocardial ischemia -Abnormal >1mm horizontal/downsloping at .08sec past “J” point.
myocardial perfusion imaging spect
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)
mpi radiopharmaceuticals
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)
thallium mpi prep
ThalliumMPI Prep

MI ruled out by cardiac markers

NPO 6-12 hrs, NO CAFFEINE 24 hrs

Wgt. <350 lbs.


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

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
  • Asthma/Severe COPD (can induce bronchospasm)
  • Hypotension
  • Recent CVA (within 30 days)
  • NY HA Class IV CHF


  • Chest Pain
  • Headache
  • Flushing
  • Nausea
  • Transient asystole & heart block(Adenosine)
dipyridamole adenosine prep
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
  • + 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.)


    • HTN
    • Chest pain
    • Arrhythmias(PVC’s 15%, SVT/Atrial 8%, NSVT 4%)
    • Palpitations/Anxiety