Cardiac Nuclear Medicine

What is Cardiac Nuclear Medicine?

Nuclear medicine is a branch of medical imaging that uses small amounts of radioactive material to diagnose and determine the severity of or treat a variety of diseases, including many types of cancers, heart disease, gastrointestinal, endocrine, neurological disorders and other abnormalities within the body. Because nuclear medicine procedures are able to pinpoint molecular activity within the body, they offer the potential to identify disease in its earliest stages as well as a patient’s immediate response to therapeutic interventions.

Cardiac nuclear medicine is useful in diagnosing and assessing coronary artery disease. It is also used to evaluate cardiomyopathy and identify possible damage to the heart from chemotherapy or radiotherapy.

Nuclear medicine imaging procedures are noninvasive and, with the exception of intravenous injections, are usually painless medical tests that help physicians diagnose and evaluate medical conditions. These imaging scans use radioactive materials called radiopharmaceuticals or radiotracers.

Depending on the type of nuclear medicine exam, the radiotracer is either injected into the body, swallowed or inhaled as a gas and eventually accumulates in the organ or area of the body being examined. Radioactive emissions from the radiotracer are detected by a special camera or imaging device that produces pictures and provides molecular information.

In many centers, nuclear medicine images can be superimposed with computed tomography (CT) or magnetic resonance imaging (MRI) to produce special views, a practice known as image fusion or co-registration. These views allow the information from two different exams to be correlated and interpreted on one image, leading to more precise information and accurate diagnoses. In addition, manufacturers are now making single photon emission computed tomography/computed tomography (SPECT/CT) and positron emission tomography/computed tomography (PET/CT) units that are able to perform both imaging exams at the same time. An emerging imaging technology, but not readily available at this time is PET/MRI.

Cardiac nuclear medicine exams provide pictures of the distribution of blood flow to the heart muscle and function of the heart.

What are some common uses of the procedure?

Physicians use cardiac nuclear medicine studies to help diagnose cardiac disease. The symptoms include:

• unexplained chest pain.
• chest pain brought on by exercise (called angina).

Cardiac nuclear medicine imaging is also performed:

• to visualize blood flow patterns to the heart walls, called a myocardial perfusion scan.
• to evaluate the presence and extent of suspected or known coronary artery disease.
• to determine the extent of injury to the heart following a heart attack, or myocardial infarction.
• to evaluate the results of bypass surgery or other revascularization procedures designed to restore blood supply to the heart.
• in conjunction with an electrocardiogram (ECG), to evaluate heart-wall movement and overall heart function with a technique called cardiac gating.

How should I prepare?

You may be asked to wear a gown during the exam or you may be allowed to wear your own clothing.

Women should always inform their physician or technologist if there is any possibility that they are pregnant or if they are breastfeeding. See the Safety page (www.RadiologyInfo.org/en/safety/) for more information about pregnancy and breastfeeding related to nuclear medicine imaging.

You should inform your physician and the technologist performing your exam of any medications you are taking, including vitamins and herbal supplements. You should also inform them if you have any allergies and about recent illnesses or other medical conditions.

You should inform your physician if you have asthma or a chronic lung disease or have problems with your knees, hips or keeping your balance, which may limit your ability to perform the exercise needed for this procedure.

Jewelry and other metallic accessories should be left at home if possible, or removed prior to the exam because they may interfere with the procedure.

You should avoid caffeine (caffeinated as well as decaffeinated coffee, hot and cold tea, caffeinated soft drinks and energy drinks, etc.) and smoking for up to 48 hours before your examination. Your physician or radiologist may give you more specific instructions.

You should not eat or drink anything after midnight on the day of your procedure, but you may continue taking medications with small amounts of water unless your physician says otherwise. If you take beta-blocker medication (Inderal, metoprolol, etc.) you should specifically ask your physician about temporary discontinuation.

What does the equipment look like?

Nuclear medicine procedures are performed using either single photon emission computed tomography (SPECT) or positron emission tomography (PET).

The gamma camera, which is encased in metal, is capable of detecting radiation and taking pictures from different angles. A gamma camera does not emit any radiation. It may be suspended over the examination table or it may be beneath the table. Often, gamma cameras are dual-headed with one camera next to the other at a 90 degree angle. In some imaging centers, the gamma camera is located beneath the exam table and out of view. The camera may be located within a large, doughnut-shaped scanner similar in appearance to a computed tomography (CT) scanner.

SPECT uses a gamma camera that rotates around the body to produce more detailed, three-dimensional images.

Most nuclear medicine procedures use a gamma camera, a specialized camera encased in metal. Some nuclear medicine equipment has CT capabilities that help improve the images and increase the ability to combine functional imaging (nuclear medicine) and anatomic imaging (CT).

A computer aids in creating the images from the data obtained by the camera or scanner.

How does the procedure work?

With ordinary x-ray examinations, an image is made by passing x-rays through the body from an outside source. In contrast, nuclear medicine procedures use a radioactive material called a radiopharmaceutical or radiotracer, which is injected into your bloodstream, swallowed or inhaled as a gas. This radioactive material accumulates in the organ or area of your body being examined, where it gives off a small amount of energy in the form of gamma rays. A gamma camera, PET scanner, or probe detects this energy and with the help of a computer creates pictures offering details on both the structure and function of organs and tissues in your body.

In order to evaluate the coronary arteries, heart scans are often performed immediately after patients have engaged in physical exercise (called a stress test) so that blood flow throughout the heart is maximized, making any blockages of the coronary arteries easier to detect. These images of the heart are compared with heart images taken while the patient is at rest. Patients who are unable to exercise are given a drug that increases blood flow to the heart.

How is the procedure performed?

Nuclear medicine imaging is usually performed on an outpatient basis, but is often performed on hospitalized patients as well.

You will be positioned on an examination table. A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm.

The exam will usually begin with an injection of tracer while you are resting. Approximately 20 to 40 minutes after the tracer is injected, you will lie on a moveable imaging table with your arms (or in some cases your left arm only) over your head for about 15 to 20 minutes while images are recorded. Following imaging, you will undergo a stress test, which requires you to exercise either by walking on a treadmill or pedaling a stationary bicycle for a few minutes. While you exercise, the electrical activity of your heart will be monitored by electrocardiography (ECG) and your blood pressure will be frequently measured. When blood flow to the heart has reached its peak, you will be given the radiotracer through your IV. After you complete the stress test, you may be asked to drink some water. Approximately 20 to 40 minutes later you will be placed on the imaging table a second time so a second series of images can be recorded. At this time, an ECG will also be placed to image the motion of your heart.

If you are unable to use a treadmill or bicycle, you will not exercise but you will be given a drug that will increase blood flow to the heart.

Actual scanning time for each heart scan varies from 15 to 30 minutes, depending on the type of scanner used. Total time in the nuclear medicine department will be approximately two to four hours.

If the SPECT or PET scanner has CT capabilities, a short CT scan of your heart will be obtained. The CT may be obtained before or after each of the nuclear medicine imaging procedures. You will not have to get up or change positions on the table for this part of the exam as the CT is part of the nuclear medicine equipment, but you will be asked to stay very still for this portion of the exam.

When the examination is completed, you may be asked to wait until the technologist checks the images in case additional images are needed. Occasionally, more images are obtained for clarification or better visualization of certain areas or structures. The need for additional images does not necessarily mean there was a problem with the exam or that something abnormal was found, and should not be a cause of concern for you.

If you had an intravenous line inserted for the procedure, it will usually be removed unless you are scheduled for an additional procedure that same day that requires an intravenous line.

What will I experience during and after the procedure?

Except for intravenous injections, most nuclear medicine procedures are painless and are rarely associated with significant discomfort or side effects.

When the radiotracer is given intravenously, you will feel a slight pin prick when the needle is inserted into your vein for the intravenous line. When the radioactive material is injected into your arm, you may feel a cold sensation moving up your arm, but there are generally no other side effects.

You will be asked to exercise until you are either too tired to continue or short of breath, or if you experience chest pain, leg pain, or other discomfort that causes you to want to stop.

If you are given a medication to increase blood flow because you are unable to exercise, the medication may induce a brief period of feeling anxious, dizzy, nauseous, shaky or short of breath. Mild chest discomfort may also occur. Any symptoms that do develop typically resolve as soon as the infusion is complete. In rare instances, if the side effects of the medication are severe or make you too uncomfortable, other drugs can be given to stop the effects.

It is important that you remain still while the images are being recorded. Though nuclear imaging itself causes no pain, there may be some discomfort from having to remain still or to stay in one particular position during imaging.

Unless your physician tells you otherwise, you may resume your normal activities after your nuclear medicine scan. If any special instructions are necessary, you will be informed by a technologist, nurse or physician before you leave the nuclear medicine department.

Through the natural process of radioactive decay, the small amount of radiotracer in your body will lose its radioactivity over time. It may also pass out of your body through your urine or stool during the first few hours or days following the test. You should also drink plenty of water to help flush the radioactive material out of your body as instructed by the nuclear medicine personnel.

Who interprets the results and how do I get them?

A radiologist or other physician who has specialized training in nuclear medicine will interpret the images and forward a report to your referring physician.

What are the benefits vs. risks?

Benefits

• Nuclear medicine examinations offer information that is unique—including details on both function and structure—and often unattainable using other imaging procedures.
• For many diseases, nuclear medicine scans yield the most useful information needed to make a diagnosis or to determine appropriate treatment, if any.
• Nuclear medicine is less expensive and may yield more precise information than exploratory surgery.

Risks

• If you have coronary artery disease, it is possible that you could experience chest pain during the exercising or when a drug is given for the stress test. However, your heart will be monitored and if necessary, medication can be given for your chest pain.
• If life threatening cardiac disease is suspected because of the test findings, your cardiologist may consider same-day cardiovascular intervention.
• Because the doses of radiotracer administered are small, diagnostic nuclear medicine procedures result in relatively low radiation exposure to the patient, acceptable for diagnostic exams. Thus, the radiation risk is very low compared with the potential benefits.
• Nuclear medicine diagnostic procedures have been used for more than five decades, and there are no known long-term adverse effects from such low-dose exposure.
• The risks of the treatment are always weighed against the potential benefits for nuclear medicine therapeutic procedures. You will be informed of all significant risks prior to the treatment and have an opportunity to ask questions.
• Allergic reactions to radiopharmaceuticals may occur but are extremely rare and are usually mild. Nevertheless, you should inform the nuclear medicine personnel of any allergies you may have or other problems that may have occurred during a previous nuclear medicine exam.
• Injection of the radiotracer may cause slight pain and redness which should rapidly resolve.
• Women should always inform their physician or radiology technologist if there is any possibility that they are pregnant or if they are breastfeeding. See the Safety page (www.RadiologyInfo.org/en/safety/) for more information about pregnancy, breastfeeding and nuclear medicine exams.

What are the limitations of Cardiac Nuclear Medicine?

Nuclear medicine procedures can be time consuming. It can take hours to days for the radiotracer to accumulate in the part of the body under study and imaging may take up to several hours to perform, though in some cases, newer equipment is available that can substantially shorten the procedure time.

The resolution of structures of the body with nuclear medicine may not be as high as with other imaging techniques, such as CT or MRI. However, nuclear medicine scans are more sensitive than other techniques for a variety of indications, and the functional information gained from nuclear medicine exams is often unobtainable by other imaging techniques.