EMPHISIS ON PHYSIOLOGY PHYSIOLOGY REQUIRES TIME QUALITATIVE vs. QUANTITATIVE ISOTOPES TO RADIOPHARMACEUTICALS
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1 1926 Herman Blumgard used solutions of radon gas to measure what he called velocity of the circulation Blumberg and Soma Weiss wrote article in (Journal of Clinical Investigation) 1929 Werner Forssmann did the first cardiac catheterization in Eberswalde Germany Georg de Hevesy used RBC S labeled with 32 P to measure RBC volume Paul Haun used 59 Fe to measure total body hematocrit. WWII -traumatic shock stimulated considerable research in cardiology that led to the introduction of 35 S as a tracer of plasma proteins Andrew Counand and Dickinson Richards used cardiac catheterization to measure cardiac output Jeff Holter founded the Society of Nuclear Medicine Cournand, Richards and Forssmann shared the Nobel Prize Hal Anger invented the scintillation camera mTc (the nuclear medicine work horse) was commercially developed Nuclear medicine stole the show internationally Nuclear Medicine took off and Nuclear Cardiology led the way. 1
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3 EMPHISIS ON PHYSIOLOGY PHYSIOLOGY REQUIRES TIME QUALITATIVE vs. QUANTITATIVE ISOTOPES TO RADIOPHARMACEUTICALS Hierarchy of Potential Test Ordering Based on Clinical Presentation Hendel, R. C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply. 3
4 Potential Applications for Chest Pain Hendel, R. C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply. Potential Applications for Asymptomatic* Patients Hendel, R. C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply. 4
5 Prior Test Results* Hendel, R. C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply. Perioperative Evaluation Hendel, R. C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply. 5
6 Postrevascularization Hendel, R. C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply. Thallium 201 A cyclotron produced potassium (K+) analog, first introduced in the early 1970s. Cyclotron Produced Physical Half Life hours. Emits 2 gamma rays at energies 135 and 167 kev 201Hg x-rays 60 to 80 kev range 99mTc Labeled Agents Reactor produced. 6 hour physical Half Life. Emits 140 kev gamma ray. 6
7 Thallium-201 Advantages Reperfusion into viable tissue. uptake in lungs after exercise is a marker for CAD. Disadvantages Stress imaging must begin soon. Low photon energy Resolution (blur-o-grams) Relatively long T ½ 73.1 hours Minimized optimal gated SPECT 99m Tc- sestamibi- tetrofosmin Advantages Relatively fixed in myocardium count rate = improved resolution More suitable photon energy Short T ½ 6 hours Well suited for gated SPECT images Dose allows for first pass acquisition Disadvantages 2 doses are needed Hepatobiliary and GI artifacts * Patient Identifiers * NPO 4-6 hours * Caffeine? * Medications, Allergies, Asthma * Beta Blockers, block the effects of adrenaline HR and BP * Pacemaker? * 12 Lead ECG, Blood Pressure, IV. * LBBB? * Physician, Cardiology Tech, Nuclear Medicine Tech. * 85% of predicted MHR or Double product of 25,000. * Exercise is reported in metabolic equivalents (METS). * Absolute contraindications, Relative contraindications 7
8 Treadmill Exercise AHA Guidelines ECG, Defibrilator, cardiac emergency pharmaceuticals Supervised by properly trained nurses, PA s, exercise physiologists, and med techs under the direct supervision of a qualified physician. Advanced and Basic Life support training. Exercise capacity is measured in metabolic equivalents (METS) Bruce protocol. Patient selection, patient prep, consent forms, radiation safety. Pharmacologic Stress Dipyridamole Adenosine Regadenosine Dobutamine Arbutimine Coronary Vasodilators Cardiac Positive inotropic agents 8
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22 Functional capacity of the heart. Ejection Fraction (EF) Evaluate wall motion. Kinesis- Hypokenisis-Akinesis- Dyskinesis Estimate cardiac output. Assess diastolic function. Evaluate shunts 22
23 Higher resolution Myocardial viability Stunned or hibernating myocardium Fluorine 18 Rubidium 82 Nitrogen 13 Oxygen 15 23
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