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NUCLEAR MEDICINE PROTOCOL Myocardial Perfusion Imaging: Adenosine Stress Low Dose Tc-99m with AC PROTOCOL #: NMC550 CDM codes: 16002165 16003025 16078464 16078478 Dr. Esteves REV. DATE: 02-15-2006 (RP: Tc-99m Sestamibi/dose) (Pharm: Adenoscan/30 mg) (Myocardial Perfusion Imaging, SPECT single) (Myocardial Perfusion Imaging, wall motion)

PREPARED BY: APPROVED BY:

_____________________________ Supervisor, Nuclear Medicine

_______ Date

___________________________ Raghuveer K. Halkar, M.D. Director, Nuclear Medicine

_________ Date

SCOPE: The Myocardial Perfusion Study demonstrates the distribution of blood flow and perfusion to the myocardium at stress. In addition, the eletrocardiographic gated study provides assessment of left ventricular wall motion and ejection fraction. INDICATIONS: EXAM TIME: 2 hours PATIENT PREPARATION: a) The patient should be off: 1) Beta-blockers up to 24-48 hours. 2) Long acting nitrates for at least 4 hours, nitroglycerin for at least 1 hour. 3) Calcium channel blockers 24-48 hours. 4) Caffeine for 24-36 hours prior to pharmacologic stress with dipyridamole or adenosine. b) The patient should be fasting for a minimum 6 hours. c) Record the patient's height, weight, chest size and, for females, bra size. This information assists in identifying and anticipating attenuation artifacts in the tomographic images. d) Carefully instruct the patient not to move during the SPECT acquisition. e) The patient should drink a glass (150-200 ml) of water just before both rest and stress acquisitions. RADIOPHARMACEUTICAL: Tc-88m Sestamibi Dosing Chart Patient Weight (lbs) Up to 200 200-300 over 300 Tc-99m Sestamibi (Cardiolite) according to chart below. Tc-99m Sestamibi Dose (mCi) Stress 10 12 15 Cardiac risk stratification following chest pain or equivalent.

TECHNIQUE OF ADMINISTRATION: Pharmacological stress with adenosine is the preferred stress mode. Only when specified by the cardiologist or cardiac fellow an exercise stress will be performed. For pharmacological stressing ­ see Pharmacological Stress protocol. Since the injection is made while the Emory University Hospital Myocardial Perfusion Imaging: Adenosine Stress Low Dose Tc-99m with AC Cardiac Nuclear Medicine Protocol Manual 1

patient is at stress, an intravenous line is placed prior to the beginning of adenosine infusion. The intravenous line should be placed in the medial (brachial) vein of the antecubital fossa. The radiopharmaceutical is then injected 1 minute before the anticipated end of the patient's exercise endurance. MATERIALS AND EQUIPMENT: 1) Gamma camera: Philips Vertex or GE MG 2) Collimators: Low-energy high resolution parallel hole collimator (Philips VXHR, GE LEHR) 3) Cardiac gating device INSTRUMENTATION & SETUP PARAMETERS: Photopeak: 20% window centered at 140 KeV for Tc-99m Scatter: 12% Centered on 118 keV Transmission: 20% Centered on 100 keV PATIENT POSITIONING: Supine with the left arm placed above the patient's head. The patient should not move during acquisition. ACQUISITION PROTOCOL: Sestamibi Scan with Attenuation Correction The acquisition described here is performed using "Vantage MIBI" protocol on the Philips Vertex. Stress study: 1. An intravenous line and EKG leads are placed. 2. The patient undergoes pharmacological stress. 3. The radiopharmaceutical is injected 1 minute before the end of exercise. 4. At 60 minutes the patient is positioned supine for SPECT acquisition. 5. SPECT acquisition parameters: a. 180º collection arc beginning at 45º RAO and ending at 45º LPO. b. Projections: 64 or more projections. c. Time per projections: 30 seconds emission, Transmission as required by system. d. Matrix size: 64 x 64, 38 cm FOV, Roving Zoom. e. 8 frame gating DATA PROCESSING: The reconstruction quantitative processing described below: 1. Technologist will check the images for patient motion prior to the patient leaving the department or any further processing. If necessary the scan will be repeated. 2. Images are reconstructed and reoriented on the host computer using the appropriate protocol The issue of which filter to use for this low dose MIBI stress acquisition is being discussed. Till a final conclusion is reached we will use the standard stress Tc MIBI filters only. 3. Images are transferred to the Emory Cardiac Toolbox Processing PC for quantitative processing. The transfer protocol is found in the "CUSTOM MENU." The GE Xeleris transfers the data with DICOM. The data to be transferred includes: Gated Stress planar projections, rest planar projections, gated stress short axis slices, summed stress short axis slices, rest short axis slices. 4. Quantitative processing is performed on the Emory Cardiac Toolbox Processing PC by a technologist with appropriate training in the used of the Toolbox. Care should be taken to complete the following sections: Parameters, Slices, Polar Maps, and Functional Analysis. Upon completion of processing a review file is automatically transferred to the reading room for physician review. 5. Call attending physician or resident for immediate interpretation.

Emory University Hospital Myocardial Perfusion Imaging: Adenosine Stress Low Dose Tc-99m with AC Cardiac Nuclear Medicine Protocol Manual 2

OPTIONAL MANEUVERS: If images are abnormal a resting study with 30-45 mCi (other parameters as per protocol) without adenosine infusion. REFERENCES: Tausig A, Knesewitsch P, Brinkbaumer K, Tatsch K, Hahn K. Is a low-dose Tc-99m-MIBI protocol suitable for first-pass RNV? Nucl Med Commun. 2000 Oct;21(10):965-70. Schroeder-Tanka JM, Tiel-van Buul MM, van der Wall EE, Roolker W, Lie KI, van Royen EA. Should imaging at stress always be followed by imaging at rest in Tc-99m MIBI SPECT? A proposal for a selective referral and imaging strategy. Int J Card Imaging. 1997 Aug;13(4):323-9.

Emory University Hospital Myocardial Perfusion Imaging: Adenosine Stress Low Dose Tc-99m with AC Cardiac Nuclear Medicine Protocol Manual 3

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