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Since the publication of the European Association of Nuclear Medicine (EANM) procedural guidelines for radionuclide myocardial perfusion imaging (MPI) in 2005, many small and some larger steps of progress have been made, improving MPI procedures. In this paper, the major changes from the updated 2015 procedural guidelines are highlighted, focusing on the important changes related to new instrumentation with improved image information and the possibility to reduce radiation exposure, which is further discussed in relation to the recent developments of new International Commission on Radiological Protection (ICRP) models. Introduction of the selective coronary vasodilator regadenoson and the use of coronary CT-contrast agents for hybrid imaging with SPECT/CT angiography are other important areas for nuclear cardiology that were not included in the previous guidelines. A large number of minor changes have been described in more detail in the fully revised version available at the EANM home page: https://eanm.org/wp-content/uploads/2025/04/2015_myocardial_perfusion.pdf .

Objective To determine the accuracy of iodine quantification with dual energy computed tomography (DECT) in two high-end CT systems with different spectral imaging techniques. Methods Five tubes with different iodine concentrations (0, 5, 10, 15, 20 mg/ml) were analysed in an anthropomorphic thoracic phantom. Adding two phantom rings simulated increased patient size. For third-generation dual source CT (DSCT), tube voltage combinations of 150Sn and 70, 80, 90, 100 kVp were analysed. For dual layer CT (DLCT), 120 and 140 kVp were used. Scans were repeated three times. Median normalized values and interquartile ranges (IQRs) were calculated for all kVp settings and phantom sizes. Results Correlation between measured and known iodine concentrations was excellent for both systems ( R  = 0.999–1.000, p  < 0.0001). For DSCT, median measurement errors ranged from −0.5% (IQR −2.0, 2.0%) at 150Sn/70 kVp and −2.3% (IQR −4.0, −0.1%) at 150Sn/80 kVp to −4.0% (IQR −6.0, −2.8%) at 150Sn/90 kVp. For DLCT, median measurement errors ranged from −3.3% (IQR −4.9, −1.5%) at 140 kVp to −4.6% (IQR −6.0, −3.6%) at 120 kVp. Larger phantom sizes increased variability of iodine measurements ( p  < 0.05). Conclusion Iodine concentration can be accurately quantified with state-of-the-art DECT systems from two vendors. The lowest absolute errors were found for DSCT using the 150Sn/70 kVp or 150Sn/80 kVp combinations, which was slightly more accurate than 140 kVp in DLCT. Key Points • High - end CT scanners allow accurate iodine quantification using different DECT techniques . • Lowest measurement error was found in scans with largest photon energy separation . • Dual - source CT quantified iodine slightly more accurately than dual layer CT .

Suspected coronary artery disease (CAD) is one of the most common, potentially life-threatening diagnostic problems clinicians encounter. However, no large outcome-based randomized trials have been performed to guide the selection of diagnostic strategies for these patients. The PROMISE study is a prospective, randomized trial comparing the effectiveness of 2 initial diagnostic strategies in patients with symptoms suspicious for CAD. Patients are randomized to either (1) functional testing (exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram) or (2) anatomical testing with ≥64-slice multidetector coronary computed tomographic angiography. Tests are interpreted locally in real time by subspecialty certified physicians, and all subsequent care decisions are made by the clinical care team. Sites are provided results of central core laboratory quality and completeness assessment. All subjects are followed up for ≥1 year. The primary end point is the time to occurrence of the composite of death, myocardial infarction, major procedural complications (stroke, major bleeding, anaphylaxis, and renal failure), or hospitalization for unstable angina. More than 10,000 symptomatic subjects were randomized in 3.2 years at 193 US and Canadian cardiology, radiology, primary care, urgent care, and anesthesiology sites. Multispecialty community practice enrollment into a large pragmatic trial of diagnostic testing strategies is both feasible and efficient. The PROMISE trial will compare the clinical effectiveness of an initial strategy of functional testing against an initial strategy of anatomical testing in symptomatic patients with suspected CAD. Quality of life, resource use, cost-effectiveness, and radiation exposure will be assessed.

Myocardial perfusion imaging plays a central role in the management of patients with known or suspected coronary artery disease (CAD) and increasingly in patients with suspected ischemia with normal coronary arteries (INOCA) as well as anomalous origins of the coronary arteries and Kawasaki disease. Stress perfusion cardiovascular magnetic resonance (CMR) is recognized by international guidelines, with several Class 1 indications for the detection of abnormal myocardial blood flow in these clinical scenarios and offers excellent diagnostic accuracy and independent prognostic value. While visual interpretation of the perfusion data is the prevailing analysis method in clinical practice, quantitative perfusion CMR is at least as accurate for the detection of significant obstructive CAD and provides a more accurate estimation of the total ischemic burden in patients with CAD. Moreover, quantitative myocardial perfusion analysis provides unique insights into the pathophysiology of myocardial ischemia, including microvascular disease in INOCA. Quantitative perfusion CMR can be fully automated, is user-independent, and may facilitate more widespread use of the modality. The aim of this Society for Cardiovascular Magnetic Resonance (SCMR) expert consensus document is to provide recommendations for the acquisition and analysis of quantitative myocardial perfusion CMR to facilitate standardization of methodology. This paper also discusses research and development goals to address current limitations, to ensure data reliability and validity, to create the basis for future multi-vendor and multicenter research, and to broaden the clinical use of quantitative perfusion CMR.

ObjectiveTo assess the cost-effectiveness of management strategies for patients presenting with chest pain and suspected coronary heart disease (CHD): (1) cardiovascular magnetic resonance (CMR); (2) myocardial perfusion scintigraphy (MPS); and (3) UK National Institute for Health and Care Excellence (NICE) guideline-guided care.MethodsUsing UK data for 1202 patients from the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 trial, we conducted an economic evaluation to assess the cost-effectiveness of CMR, MPS and NICE guidelines. Health outcomes were expressed as quality-adjusted life-years (QALYs), and costs reflected UK pound sterling in 2016–2017. Cost-effectiveness results were presented as incremental cost-effectiveness ratios and incremental net health benefits overall and for low, medium and high pretest likelihood of CHD subgroups.ResultsCMR had the highest estimated QALY gain overall (2.21 (95% credible interval 2.15, 2.26) compared with 2.07 (1.92, 2.20) for NICE and 2.11 (2.01, 2.22) for MPS) and incurred comparable costs (overall £1625 (£1431, £1824) compared with £1753 (£1473, £2032) for NICE and £1768 (£1572, £1989) for MPS). Overall, CMR was the cost-effective strategy, being the dominant strategy (more effective, less costly) with incremental net health benefits per patient of 0.146 QALYs (−0.18, 0.406) compared with NICE guidelines at a cost-effectiveness threshold of £15 000 per QALY (93% probability of cost-effectiveness). Results were similar in the pretest likelihood subgroups.ConclusionsCMR-guided care is cost-effective overall and across all pretest likelihood subgroups, compared with MPS and NICE guidelines.

Background Clinical evaluation of stress perfusion cardiovascular magnetic resonance (CMR) is currently based on visual assessment and has shown high diagnostic accuracy in previous clinical trials, when performed by expert readers or core laboratories. However, these results may not be generalizable to clinical practice, particularly when less experienced readers are concerned. Other factors, such as the level of training, the extent of ischemia, and image quality could affect the diagnostic accuracy. Moreover, the role of rest images has not been clarified. The aim of this study was to assess the diagnostic accuracy of visual assessment for operators with different levels of training and the additional value of rest perfusion imaging, and to compare visual assessment and automated quantitative analysis in the assessment of coronary artery disease (CAD). Methods We evaluated 53 patients with known or suspected CAD referred for stress-perfusion CMR. Nine operators (equally divided in 3 levels of competency) blindly reviewed each case twice with a 2-week interval, in a randomised order, with and without rest images. Semi-automated Fermi deconvolution was used for quantitative analysis and estimation of myocardial perfusion reserve as the ratio of stress to rest perfusion estimates. Results Level-3 operators correctly identified significant CAD in 83.6% of the cases. This percentage dropped to 65.7% for Level-2 operators and to 55.7% for Level-1 operators ( p  < 0.001). Quantitative analysis correctly identified CAD in 86.3% of the cases and was non-inferior to expert readers ( p  = 0.56). When rest images were available, a significantly higher level of confidence was reported ( p  = 0.022), but no significant differences in diagnostic accuracy were measured ( p  = 0.34). Conclusions Our study demonstrates that the level of training is the main determinant of the diagnostic accuracy in the identification of CAD. Level-3 operators performed at levels comparable with the results from clinical trials. Rest images did not significantly improve diagnostic accuracy, but contributed to higher confidence in the results. Automated quantitative analysis performed similarly to level-3 operators. This is of increasing relevance as recent technical advances in image reconstruction and analysis techniques are likely to permit the clinical translation of robust and fully automated quantitative analysis into routine clinical practice.

Coronary artery disease (CAD) burden for society is expected to steeply increase over the next decade. Improved feasibility and efficiency of preventive strategies is necessary to flatten the curve. Acute myocardial infarction (AMI) is the main determinant of CAD-related mortality and morbidity, and predominantly occurs in individuals with more advanced stages of CAD causing subclinical myocardial ischemia (obstructive CAD; OCAD). Unfortunately, OCAD can remain subclinical until its destructive presentation with AMI or sudden death. Current primary preventive strategies are not designed to differentiate between non-OCAD and OCAD and the opportunity is missed to treat individuals with OCAD more aggressively. EARLY-SYNERGY is a multicenter, randomized-controlled clinical trial in individuals with coronary artery calcium (CAC) presence to study (1.) the yield of cardiac magnetic resonance stress myocardial perfusion imaging (CMR-MPI) for early OCAD diagnosis and (2) whether early OCAD diagnosis improves outcomes. Individuals with CAC score ≥300 objectified in 2 population-based trials (ROBINSCA; ImaLife) are recruited for study participation. Eligible candidates are randomized 1:1 to cardiac magnetic resonance stress myocardial perfusion imaging (CMR-MPI) or no additional functional imaging. In the CMR-MPI arm, feedback on imaging results is provided to primary care provider and participant in case of guideline-based actionable findings. Participants are followed-up for clinical events, healthcare utilization and quality of life. EARLY-SYNERGY is the first randomized-controlled clinical trial designed to test the hypothesis that subclinical OCAD is widely present in the general at-risk population and that early differentiation of OCAD from non-OCAD followed by guideline-recommended treatment improves outcomes.

In light of recent focus on diagnostic imaging, cardiac SPECT imaging needs to become a shorter test with lower radiation exposure to patients. Recently introduced Cadmium Zinc Telluride (CZT) cameras have the potential to achieve both goals. During a 2-month period patients presenting for a Tc-99m sestamibi SPECT MPI study were imaged using a CZT camera using a low-dose rest-stress protocol (5 mCi rest and 15 mCi stress doses). Patients ≥250 lbs or a BMI ≥35 kg/m2 were excluded. Rest images were processed at 5- and 8-minute acquisition times and stress images at 3- and 5-minute acquisition times. A subset of patients had stress imaging performed using both conventional and CZT SPECT cameras. Image acquisition times and SPECT camera images were compared based on total counts, count rate, image quality, and summed rest and stress scores. Twelve month clinical follow-up was also obtained. 131 patients underwent the study protocol (age 64.9 ± 9.8 years, 54.2% male). There was no significant difference in image quality and mean summed scores between 5- and 8-minute rest images and between 3- and 5-minute stress images. When compared to a conventional SPECT camera in 27 patients, total rest and stress perfusion deficits and calculated LVEF were similar (r = 0.94 and 0.96, respectively). At 12 months there was a benign prognosis in patients with normal perfusion. The effective dose was 5.8 mSv for this protocol which is 49.2% less than conventional Tc-99m studies and 75.7% less than conventional Tl-201/Tc-99m dual isotope studies. New SPECT camera technology with low isotope dose significantly reduces ionizing radiation exposure and imaging times compared to traditional protocols while maintaining image quality and diagnostic accuracy.

IntroductionThere is conflicting evidence regarding the benefits of percutaneous coronary intervention (PCI) in patients with grey zone fractional flow reserve (GZFFR artery) values (0.75–0.80). The prevalence of ischaemia is unknown. We wished to define the prevalence of ischaemia in GZFFR artery and assess whether PCI is superior to optimal medical therapy (OMT) for angina control.MethodsWe enrolled 104 patients with angina with 1:1 randomisation to PCI or OMT. The artery was interrogated with a Doppler flow/pressure wire. Patients underwent Magnetic Resonance Imaging (MRI) with follow-up at 3 and 12 months. The primary outcome was angina status at 3 months using the Seattle Angina Questionnaire (SAQ).Results104 patients (age 60±9 years), 79 (76%) males and 79 (76%) Left Anterior Descending (LAD) stenoses were randomised. Coronary physiology and SAQ were similar. Of 98 patients with stress perfusion MRI data, 17 (17%) had abnormal perfusion (≥2 segments with ≥25% ischaemia or ≥1 segment with ≥50% ischaemia) in the target GZFFR artery. Of 89 patients with invasive physiology data, 26 (28%) had coronary flow velocity reserve <2.0 in the target GZFFR artery. After 3 months of follow-up, compared with patients treated with OMT only, patients treated by PCI and OMT had greater improvements in SAQ angina frequency (21 (28) vs 10 (23); p=0.026) and quality of life (24 (26) vs 11 (24); p=0.008) though these differences were no longer significant at 12 months.ConclusionsNon-invasive evidence of major ischaemia is uncommon in patients with GZFFR artery. Compared with OMT alone, patients randomised to undergo PCI reported improved symptoms after 3 months but these differences were no longer significant after 12 months.Trial registration number NCT02425969.

A recently developed camera system for high-speed SPECT (HS-SPECT) myocardial perfusion imaging shows excellent correlation with conventional SPECT. Our goal was to test the diagnostic accuracy of an automated quantification of combined upright and supine myocardial SPECT for detection of coronary artery disease (CAD) (≥ 70% luminal diameter stenosis or, in left main coronary artery, ≥ 50% luminal diameter stenosis) in comparison to invasive coronary angiography (ICA). We studied 142 patients undergoing upright and supine HS-SPECT, including 56 consecutive patients (63% men; mean age ± SD, 64 ± 13 y; 45% exercise stress) without known CAD who underwent diagnostic ICA within 6 mo of HS-SPECT and 86 consecutive patients with a low likelihood of CAD. Reference limits for upright and supine HS-SPECT were created from studies of patients with a low likelihood of CAD. Automated software adopted from supine-prone analysis was used to quantify the severity and extent of perfusion abnormality and was expressed as total perfusion deficit (TPD). TPD was obtained for upright (U-TPD), supine (S-TPD), and combined upright-supine acquisitions (C-TPD). Stress U-TPD ≥ 5%, S-TPD ≥ 5%, and C-TPD ≥ 3% myocardium were considered abnormal for per-patient analysis, and U-TPD, S-TPD, and C-TPD ≥ 2% in each coronary artery territory were considered abnormal for per-vessel analysis. On a per-patient basis, the sensitivity was 91%, 88%, and 94% for U-TPD, S-TPD, and C-TPD, respectively, and specificity was 59%, 73%, and 86% for U-TPD, S-TPD, and C-TPD, respectively. C-TPD had a larger area under the receiver-operating-characteristic curve than U-TPD or S-TPD for identification of stenosis ≥ 70% (0.94 vs. 0.88 and 0.89, P < 0.05 and not significant, respectively). On a per-vessel basis, the sensitivity was 67%, 66%, and 69% for U-TPD, S-TPD, and C-TPD, respectively, and specificity was 91%, 94%, and 97% for U-TPD, S-TPD, and C-TPD, respectively (P = 0.02 for specificity U-TPD vs. C-TPD). In this first comparison of HS-SPECT with ICA, new automated quantification of combined upright and supine HS-SPECT shows high diagnostic accuracy for detecting clinically significant CAD, with findings comparable to those reported using conventional SPECT.