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New Challenges in Nuclear Cardiology PracticeBrian G. Abbott, MD, FACC, FASNC, FAHA
President, ASNC 2016
Associate Professor of MedicineWarren Alpert Medical School of Brown University
Director, Cardiovascular ImagingCardiovascular Institute, Rhode Island, Miriam and Newport Hospitals
Providence, Rhode Island, USA
New Challenges in Nuclear Cardiology Practice
• Training and education (PET)• Isotope shortages• Appropriate use• Emerging technologies and techniques• Radiation dose reduction strategies• International Growth of Nuclear Cardiology
Nuclear Cardiology TrainingUSA
• Cardiologists learn Nuclear Cardiology as part of Cardiology Fellowship
• Some Nuclear Medicine and Radiologists• Most Nuclear Cardiology is outpatient
SPECT with small “Cardio-focal” cameras• Compared to other countries less coronary
angiography as first test• CTA being used more widely
US Training Guidelines in Nuclear Cardiology
(for Cardiologists)• Focus on SPECT MPI
– Principles of imaging, interpretation– Radiation safety
• Limited access to Cardiac PET– Only a minority of the190 Cardiology
Fellowships have Cardiac PET• Gain knowledge rather than experience• ASNC- PET Curriculum and Certification
Cardiac PET
• Perfusion (Rb-82 or N-13 NH3)• Quantitative Myocardial Blood Flow• PET perfusion and CTA anatomy• Sarcoidosis with FDG-PET• Amyloidosis with Tc-99m Pyrophosphate
Hybrid PET/CTA
Danad et al, J Nucl Cardiol2013
A: NormalB: RCA, mild defect
elsewhereC: LAD, large
anterior defectD: No CAD, diffuse
abnormal CFR
Eve
nt ra
te (%
/yea
r)
Adjusted Cardiac Event Free Survival
Days
SSS<4 MFR2
SSS4 MFR2
SSS<4 MFR<2
SSS4 MFR<2
Ziadi M. JACC 2011;58:740
* SSS<4 MFR<2 vs 2: HR 2.4 (1.4, 4.4) P=0.003
** SSS4 MFR<2 vs 2: HR 4.6 (2.2, 9.7) P<0.001
Rb-82 PET Flow Quantification
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Potential Required for Cardiac PET Training
• Development of Clinical Competency statement specific to PET
• Identification of PET training sites• Enhanced educational opportunities in
PET for life long learning, CME• Technologist training
– PET as part of Nuclear Medicine– Training in CT
Challenges in Nuclear Cardiology Practice
• Training and Education• Isotope shortages• Appropriate use• Emerging technologies and techniques• Radiation dose reduction strategies• International Growth of Nuclear Cardiology
Concerning Pattern: Decreasing Rate of Technetium Use
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Cardiac Catheterization within 90 daysPr
oportio
n of SPECT
MPI with
Tc‐99m
Proportion of SPECT MPI with Tc‐99m Rate of Catheterization within 90 Days After SPECT MPI
Murthy, et al. JAMA Cardiology 2016 1:616‐7
Moly‐99M Shortage
Medicare Trends: Alternative Testing
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Murthy, et al. JAMA Cardiology 2016 1:616‐7
Medicare Trends: Use of Tc‐99 and Downstream Catheterization
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2008 2009 2010 2011 2012
Cardiac Catheterization within 90 daysPr
oportio
n of SPECT
MPI with
Tc‐99m
Proportion of SPECT MPI with Tc‐99m Rate of Catheterization within 90 Days After SPECT MPI
During Shortage:Odds Ratio of 1.09 [95% CI 1.07‐1.10]
for Downstream Cath
Excess of 5715 Cardiac Caths inMedicare Alone During 6 Months
Murthy, et al. JAMA Cardiology 2016 1:616‐7
Strategies to Cope with Mo-99m Supply Disruption
• Reduce activity administered– Stress only/stress first imaging– Advanced reconstruction / CZT cameras
• Alternative testing– PET– CTA– Echo– MRI
• Thallium-201 SPECT
Challenges in Nuclear Cardiology Practice
• Training and Education• Isotope shortages• Appropriate use• Emerging technologies and techniques• Radiation dose reduction strategies• International Growth of Nuclear Cardiology
Physician Specialty Appropriate and Inappropriate Use Rate
.
Appropriate Use of Cardiac Stress Testing with Imaging: A Systematic Review and Meta-Analysis.Ladapo JA, Becker S, O’Donnell M, Jumkhawala SA, Douglas PS. PLoS One. 2016; 11(8): e0161153
Inappropriate/Rarely Appropriate Use Rates of Stress Echocardiography and MPI by Patient Enrollment Year
J Am Coll Cardiol. 2016;67(13_S):1625-6
Appropriate Use of Stress MPI by Non-Cardiologists Improved with Education
• Direct contact • Case Discussions with requesting providers • Educational Case Vignette series.
J Am Coll Cardiol. 2016;67(13_S):1625-6
Appropriate Use of Stress MPI by Non-Cardiologists Improved with Education
• Direct contact • Case Discussions with requesting providers • Educational Case Vignette series.
Use of a Learning Community and Online Evaluation of Utilization for
SPECT Myocardial Perfusion Imaging
J Am Coll Cardiol Img. 2013;6(7):823-829
Formation of Optimal Cardiovascular Utilization Strategies(FOCUS)
Challenges in Nuclear Cardiology Practice
• Training and Education• Isotope shortages• Appropriate use• Emerging technologies and techniques• Radiation dose reduction strategies• International Growth of Nuclear Cardiology
Common Features of New Camera Systems
• Multiple solid state, digital detectors– Improved energy and spatial resolution
• Collimators with larger effective diameter or multi-pinhole design
• Field of view limited to heart • CT attenuation correction on some systems
New Technologies Improve Image Quality
Iterative ReconstructionScatter CorrectionResolution RecoveryAttenuation Correction
New Technology not in Widespread Use
• Co$t– CZT and PET cameras– PET radiotracers, Rb82 or Cyclotron
• Declining Reimbursement for Nuclear Cardiology procedures
• Declining Utilization (AUC, Payors)• Attenuation correction not reimburesed• Lack of CT training with SPECT and PET
Challenges in Nuclear Cardiology Practice
• Training and Education• Isotope shortages• Appropriate use• Emerging technologies and techniques• Radiation dose reduction strategies• International Growth of Nuclear Cardiology
Stress Testing Protocols
• Stress- first protocols
• Radiation dose reduced avoiding unnecessary rest images
% S
urvi
val
Years%
Sur
viva
l
Number at RiskStress-Only 8034 6996 4981 3243 1196Stress+Rest 8820 7413 4525 2107 732
0 2 4 6 8
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Stress-OnlyStress + Rest
Log-rank p=0.02 (unadjusted)
p=0.89 (adjusted)
Chang SM, et al. J Am Coll Cardiol 2010;55:221-30
Stress-only vs Additional Rest Imaging: Survival
Stress-Only vs. Additional Rest Imaging
89% of patients had either a history of CAD (31%) or at least intermediate risk for CAD (58%)
Stress-only MPI
0.67%N=10,436
0.93%N=12,057
RR=0.85 (CI: 0.63-1.15, p=0.29)
Pooled annual event rates in 22,443 patients
Shaw LJ et al, J Nucl Cardiol 2012
High Efficiency SPECT CameraSolid State CZT
Supine 8 min
Prone 4 min
Stress Only5 mCi Tc-99m Tetrofosmin
Effective Dose <2 mSv
Radiation Dose Reduction
• Avoid Thallium 201• Stress-first protocols- low dose• High Sensitivity CZT SPECT Camera• Software for processing low dose studies• PET for lower radiation exposure• Attenuation Correction- less false positive
studies, reduce unnecessary angiography
Challenges in Nuclear Cardiology Practice
• Training and Education• Isotope shortages• Appropriate use• Emerging technologies and techniques• Radiation dose reduction strategies• International Growth of Nuclear Cardiology
Disability Adjusted Life-Years Lost due to Cardiovascular Disease per 100,000
<900900-16501650-2300
2300-30003000-37003700-4400
WHO Disease and injury
6500-72007200-7900>7900
4400-51005100-58005800-6500
Disability Adjusted Life-Years Lost due to Cardiovascular Disease per 100,000
<900900-16501650-2300
2300-30003000-37003700-4400
WHO Disease and injury
6500-72007200-7900>7900
4400-51005100-58005800-6500
Delbeke & Segall. J Nuc Med 2011
Utilization of SPECT Myocardial Perfusion Imaging per 100,000
• 4500 Members in US and Worldwide– Physicians– Nuclear Medicine Technologists– Physicists
• Education• Quality standards, appropriate use criteria• Guidelines• Research
ASNC International Membership
South America
35%
Africa 4%
Europe21%
Asia 32%
Australia 8%
> 400 International Members
62 Countries
The first cardiovascular registry to focus on SPECT and PET imaging studies
www.asnc.org/imageguide
• Appropriate Use• Performance Measures• Radiation Dose• Laboratory “Report Card”• Quality Improvement• Free to ASNC members