Asnc imaging guidelines for nuclear cardiology procedures - standardized reporting of radionuclide myocardial perfusion and function

Standardized reporting of radionuclidemyocardial perfusion and function Peter L. Tilkemeier, MD,a C. David Cooke, MSEE,b Gabriel B. Grossman, MD,PhD,c,d Benjamin D. McCallister Jr, MD,e and R. Parker Ward, MDf multiple formats consisting of clear and defined struc-tured data elements.
The myocardial perfusion imaging report is the final The appearance of the standardized report can, product of a complicated process designed to produce and should, vary from user to user. Report structure high quality and valuable patient data. As such, it must does not rely on a single standard appearance, but contain sufficient information to convey the details of rather on the content and utilization of structured data the procedure while simultaneously remaining succinct.
elements. For example, one laboratory may choose to The report should provide a basic ‘‘bottom line’’ result use a report that is formatted in paragraphs while to the referring physician.-It should follow a defined another may use a tabular format, or even a combi- structure and contain standardized data elements so that nation of the two. All are structured reports as long as test results are portable as patients move through the the data are derived from defined, structured data healthcare system. The structured report is an integral part of the electronic health care record, and is necessary Reports have limited utility if they cannot be used for defining quality in all nuclear cardiology practices.
to communicate and transfer information from one As the healthcare community moves away from open source to another. The use of structured data and reporting, the implementation of structured reporting is reporting, as defined by the Digital Imaging and expected to improve quality and outcomes and to reduce and Integrating the Healthcare Enterprise (IHE) stan- The myocardial perfusion imaging report is used for dards, allows this communication to occur. The various purposes including patient care, research, quality DICOM standard for stress reporting includes the data assurance, reimbursement documentation, and incorpo- elements for structured nuclear cardiology reporting.
ration of data into integrated imaging databases. The These elements have been adopted by developers and report may also be used by a variety of interested parties including physicians, researchers, insurers, and industry.
implementation. IHE has also published a standard for To accommodate all of these functions and users, one the communication of data among different vendor should be able to rearrange the imaging report into The American College of Cardiology (ACC) has also published two relevant reporting documents. The‘‘Health Policy Statement on Structured Reporting inCardiovascular Imaging’’defines the generally accepted From Miriam Hospital,a Providence, RI; Emory University Hospital,b position of the cardiovascular community regarding Atlanta, GA; Hospital Moinhos de Vento,c Rio Grande do Sul,Brazil; Cardionuclear-Instituto de Cardiologia,d Porto Alegre, Bra- structured reporting. The ‘‘Key Data Elements and Def- zil; Michigan Heart and Vascular Institute,e Ypsilanti, MI; initions for Cardiac Imaging: A Report of the American University of Chicago,f Chicago, IL.
College of Cardiology/American Heart Association Task Unless reaffirmed, retired, or amended by express action of the Board Force on Clinical Data Standardsis designed to of Directors of the American Society of Nuclear Cardiology, thisImaging Guideline shall expire as of May 2014.
facilitate the reporting of imaging studies in multi- Reprint requests: Peter L. Tilkemeier, MD, Miriam Hospital, Provi- modality environments by coordinating the definitions of some data elements used for myocardial perfusion and functional imaging. This has resulted in a ‘‘redefinition’’ Copyright Ó 2009 by the American Society of Nuclear Cardiology.
of some of the data elements in prior versions of ASNC imaging guidelines for nuclear cardiology procedures the nuclear cardiology standard. This updated image reporting guideline incorporates and harmonizes these recommendations, unifies prior ASNC documents, andexpands the imaging guidelines to include exercise and resting first-pass radionuclide angiography (FPRNA), equilibrium radionuclide angiocardiography (ERNA), positron emission tomography (PET), and viability This document will address both structured reports as well as structured data. Structured data elements will be reported in tables pertaining to each of the broad areas a structured report should contain. These tables consist of the variables, their description, format (i.e., text, numeric, date), priority (i.e., required, recom- mended, or optional), and allowed response(s). The structured reports portion of the document will discuss the use of the standard data elements to construct a Due to considerable recent development and matur- ing of the tools required for widespread clinical implementation of structured reporting, the current doc- ument is an update of an earlier image reporting guideline that was developed by the American Society of Nuclear Cardiology (ASNC).Given this significant degree of development, ASNC supports the mandatory use ofstructured reporting using standardized data elements in ECG, Electrocardiographic; LV, left ventricular; RV, right myocardial perfusion imaging reports. This should be ventricular; FPRNA, first-pass radionuclide angiography; implemented as part of the laboratory accreditation ERNA, equilibrium radionuclide angiocardiography.
This publication is designed to provide imaging guidelines for physicians and technologists who are A few of the general data elements, and many of the qualified to practice nuclear cardiology. While the specific data elements, may be recorded at the time that information supplied in this document has been care- the test is performed. Some elements may not be fully reviewed by experts in the field, the document required in the final report. This may be the case for should not be considered medical advice or a profes- some fields that are required for quality reporting, but not necessarily for reporting the findings from an indi-vidual patient’s study for specific patient management.
Many different structured reports can be generated from a set of structured data. The potential reports include:a clinical patient-specific report, summary quality report, billing report, and other reports as needed. The According to the ‘‘Health Policy Statement on greatest strength to structured data utilization is the ability Structured Reporting in Cardiovascular Imaging,’’the to generate multiple report formats with varying levels of standard components of a report include the following detail depending on the clinical or administrative need.
major headings: Administrative Information, Patient This document will harmonize these generalized Demographics, Study Referral Data, History and Risk concepts and apply them specifically to nuclear cardi- Factors, Study Description, Study Findings, and other ology. Due to the variability of the study types reporting parameters. These elements are outlined in encompassed by this document, some of the data ele- detail in ‘‘Key Data Elements and Definitions for Car- ments are specific to certain types of acquisitions, or are diac Imaging: A Report of the American College of dependent upon the study indication (e.g., viability Cardiology/American Heart Association Task Force on determination by PET imaging). Therefore, some data Clinical Data Standardswhich addresses specific elements may be required for certain acquisitions and details for each of these major headings for multiple clinical indications, while some may be optional and perhaps irrelevant for other indications.
ASNC imaging guidelines for nuclear cardiology procedures A number of the data elements contained in the tables have been derived from, and harmonized with, The Patient Demographics and Study Referral data other guideline documents, some multi-societal and section provides the clinical indications for the study.
others ASNC-specific.This update also addresses Major areas to be considered are: diagnosis of coronary additional modalities that were not included in the artery disease (CAD), extent and severity of known CAD, prior versions of the document, such as: PET, viabil- risk stratification, determination of viability, and assess- ity, FPRNA, and ERNA both at rest and with ment of acute chest pain syndromes. With the inclusion of exercise. The data elements required for reporting the the History and Risk Factors section, this would complete additional modalities have been added to specific the data elements contained in Tables and .
tables where appropriate or additional tables have The specific purpose for which the test is being per- been added to the document to cover those items that formed must be clearly identified. This provides the were specific to the modality and could not be required documentation for the medical necessity of the generalized to one of the existing table headings study and its appropriateness, and focuses the report on the question asked by the referring physician. The struc-tured data elements that relate to the indication can belocated in Table The structured reports should contain sufficient information from these areas to ensure correct The Site Administrative Data section of the report is identification of the patient. The reports must also convey the descriptor of the site performing the study. It the specific indications for the study and the pertinent includes elements such as the physical address, accred- portions of the clinical history that allow the caregivers to itation status, type of facility (e.g., hospital or office), appropriately place the imaging results in clinical context.
and insurance payer. This data may only need to be This would include the patient’s current symptoms or collected as part of the reporting process, and some other indication for which the study is being performed, elements may not be recorded in the final report current medications, cardiac history with pertinent risk factors and prior testing, and therapeutic procedures.
Hospital—outpatientNon-hospital—inpatientNon-hospita—outpatientMobile-based—inpatientMobile-based—outpatient MedicaidCommercialMilitary/VAMCNon-US insuranceSelf/none ID, Identification; ACR, American College of Radiology; ICANL, The Intersocietal Commission for the Accreditation of NuclearMedicine Laboratories; VAMC, Veterans Affairs Medical Center.
ASNC imaging guidelines for nuclear cardiology procedures Table 2. Patient demographics and study referral data Internal medicineRadiologyNuclear medicineOtherNone ID, Identification; DOB, date of birth; MD, physician or doctor of medicine; CBNC, Certification Board of NuclearCardiology; ABNM, American Board of Nuclear Medicine; ACR, American College of Radiology.
CADHeart failureCoronary risk factorsDyspneaHistory of PCIHistory of CABGAbnormal stress testAbnormal electrocardiogramArrhythmiaAngina pectorisHypertensionPalpitationsSVTSyncopeAssessment of LV functionViabilityOther ASNC imaging guidelines for nuclear cardiology procedures Atypical anginaNonanginal chest painAnginal equivalentNo chest pain Ca?? blockerNitratesDigoxinACE/ARBDiureticsAspirin, other antiplatelet agentsErectile dysfunction medicationWarfarinAnti-arrhythmicsMetforminLipid lowering agentsOther anti-hypertensivesAminophylline or theophyllineDipyridamoleInhalerDiabetic medicationsNone Ca?? blockerNitratesDigoxinACE/ARBDiureticsAspirin, other antiplatelet agentsErectile dysfunction medicationWarfarinAnti-arrhythmicsMetforminLipid lowering agentsOther anti-hypertensivesAminophylline or theophyllineDipyridamoleInhalerDiabetic medicationsNone DiabetesHypercholesterolemiaFamily historySmokingObesityMetabolic syndromePeripheral vascular diseaseErectile dysfunctionChronic kidney disease ASNC imaging guidelines for nuclear cardiology procedures s/p PCI/stents/p CABGs/p MIHistory of peripheral vascular coronary risk equivalent asdefined by ATPIII/NCEP(diabetes, PAD, etc.)) Perfusion imagingStress echoCatheterizationMRICTFPRNAERNAPETUnknownNone CAD, Coronary artery disease; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; SVT, supraven-tricular tachycardia; LV, left ventricle; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; MI, myocardialinfarction; ATP III, Adult Treatment Panel III; NCEP, National Cholesterol Education Panel; PAD, peripheral artery disease; ETT,exercise tolerance test; MRI, magnetic resonance imaging; CT, computed tomography; FPRNA, first-pass radionuclide angiog-raphy; ERNA, equilibrium radionuclide angiocardiography; PET, positron emission tomography.
ASNC imaging guidelines for nuclear cardiology procedures and estimated metabolic equivalents (METS). Forpharmacologic stress tests, the pharmacologic agent The Study Description should be the next section used, the dose received, including the infusion rate and of the structured report. This section should include all duration, hemodynamic response to the dose, and use of the parameters used in acquiring the study. It must of adjunctive exercise must be documented. The time include a description of the stress test performed, of administration of radioactivity is also required for including the type of stress test (i.e., exercise or either modality. The specific data elements for this pharmacologic). For stress tests, it is necessary to section as well as their responses can be found in include the type of protocol, duration of exercise, and its adequacy as determined by exercise time, peak heartrate, percent maximal predicted heart rate (MPHR), ExercisePharmacologicPharmacologic/exerciseOther DobutamineAdenosineAtropineRegadenosonOther (free text) BruceModified bruceNaughtonRampModified naughtonBicycle ergometerLow levelOther Peak BP achieved during test Numerical Required ASNC imaging guidelines for nuclear cardiology procedures Atypical anginaNonanginal chest painAnginal equivalentNo chest pain ClaudicationSyncopeFlushingNauseaDizzinessFatigue HypotensionHypertensionArrhythmiaClaudicationEnd of protocolOther LBBB, Left bundle branch block; METS, metabolic equivalents; HR, heart rate; BPM, beats per minute; MPHR,maximal predicted heart rate; BP, blood pressure; ECG, electrocardiographic.
The Electrocardiographic (ECG) Data pertinent to the test should be reported next. This would pretation of the ECG stress portion of the test include the presence of any baseline ECG abnor- ASNC imaging guidelines for nuclear cardiology procedures Sinus rhythmSinus bradycardiaSinus tachycardiaJunctional rhythmSVTEctopic atrial rhythmAtrial fibrillationAtrial pacedVentricular pacedAV sequential pacedOther NormalIVCDLBBBRBBBIncomplete RBBBIncomplete LBBBRBBB ? LAHBRBBB ? LPHBFirst-degree AV blockSecond-degree AV blockThird-degree AV blockPre-excitationOther NormalEarly repolarizationNonspecific ST-T HR, Heart rate; BP, blood pressure; ECG, electrocardiographic; SVT, supraventricular tachycardia; AV, atrioventricular; IV, intra-ventricular; IVCD, intraventricular conduction delay; LBBB, left bundle branch block; RBBB, right bundle branch block; LAHB, leftanterior hemiblock; LPHB, left posterior hemiblock; APC, atrial premature contraction; VPC, ventricular premature contraction.
The stress ECG interpretation must evaluate the tests and inclusion of parameters that allow calculation parameters defined in Table commenting on any of validated risk scores (e.g., the Duke treadmill score) changes from baseline with regard to either the ST segments or onset of arrhythmias. Comparison to prior ASNC imaging guidelines for nuclear cardiology procedures Sinus rhythmSinus bradycardiaSinus tachycardiaJunctional rhythmSVTEctopic atrial rhythmAtrial fibrillationAtrial pacedVentricular pacedAV sequential pacedOther NormalIVCDLBBBRBBBIncomplete RBBBIncomplete LBBBBifascicular blockRBBB ? LAHBRBBB ? LPHBFirst-degree AV blockSecond-degree AV blockThird-degree AV block VPCAtrial fibrillationSVTNon-sustained ventricular Ventricular tachycardiaVentricular fibrillation Early repolarizationNonspecific ST-T changesST depressionST elevationSecondary ST-T changes Mildly positiveModerately positiveStrongly positiveStrongly positive-ST ASNC imaging guidelines for nuclear cardiology procedures Resolution of ischemiaIschemia at lower workload ECG, Electrocardiographic; SVT, supraventricular tachycardia; AV, atrioventricular; IV, intraventricular; IVCD, intraventricular con-duction delay; LBBB, left bundle branch block; RBBB, right bundle branch block; LAHB, left anterior hemiblock; LPHB, left posteriorhemiblock; APC, atrial premature contraction; VPC, ventricular premature contraction; ETT, exercise tolerance test; METS, meta-bolic equivalents.
The structured report format continues with vari- The next data elements required for reporting are ables that define the imaging process including the left ventricle (LV) perfusion parameters. Every perfu- protocol utilized, the patient position, and radiopharma- sion defect must be quantified with regard to size (i.e., ceutical doses administered to the patient. It also includes small, medium, and large), severity (i.e., mild, moderate, their time of administration and whether attenuation severe, and background), and type (i.e., reversible, per- correction or other modalities were used. These data sistent, and mixed). The location of the defect must be elements are presented in detail in Table .
described using the standardized 17-segment model ASNC imaging guidelines for nuclear cardiology procedures Rest Tl-201/stress Tc- 99mRest Tc-99m/stress Viability onlyStress/rest Rb-82Stress/rest Tl-201Rest Rb-82/F-18 FDGRest/delayed restERNA in vivo labelingERNA in vitro labelingFPRNAOther Tc-99m sestamibiTc-99m tetrofosminRb-82N-13 ammonia Stress injection time Time of stress injection Stress imaging time Time of stress imaging Tc-99m sestamibiTc-99m tetrofosminRb-82N-13 ammoniaTc-99m DTPATc-99m HDP ASNC imaging guidelines for nuclear cardiology procedures FDG, Fluoro deoxyglucose; ERNA, equilibrium radionuclide angiocardiography; FPRNA, first-pass radionuclide angiography;SPECT, single photon emission computed tomography; DTPA, diethylene triaminepentaacetic acid; HDP, hydroxymethylenediphosphonate; PET, positron emission tomography.
(Appendix 3).The presence of apparent transient recommended for inclusion in the report and the sug- cavitary dilatation must be reported.
gested data elements to use when reporting quantitative The remaining elements in Table are recom- elements are outlined in Table . The information in these tables may be repeated as required to describe parameters. The use of quantitative image processing is Basal anteroseptalBasal inferoseptalBasal inferolateralBasal anterolateralMid-anteriorMid-anteroseptalMid-inferoseptalMid-inferiorMid-inferolateral Apical anteriorApical septalApical inferiorApical lateralApexNone ASNC imaging guidelines for nuclear cardiology procedures The information in this table may be repeated as required to describe multiple perfusion defects.
TCD,Transient cavity dilation; TID, transient ischemic dilation; LV, left ventricular; RV, right ventricular.
SSS, Summed stress score; SRS, summed rest score; SDS, summed difference score.
ASNC imaging guidelines for nuclear cardiology procedures Assessment of LV function and wall motion should reported noting both their severity (i.e., hypokinesis be performed in all patients if technically feasible with [mild, moderate, severe], akinesis, or dyskinesis) and stress and/or rest gated techniques. The report should location using the standardized 17-segment model.
describe the timing of the acquisition of the image set Optionally, LV volume data can be reported. The data (i.e., during exercise [first pass], post-stress, or at rest), elements specific to LV function are located in the global LV function (i.e., normal, mild, moderate, or Tables and . The information in these tables may severely reduced), and the quantitative LV ejection be repeated as required to describe multiple perfusion fraction. Regional wall motion abnormalities should be Mildly reducedModerately reducedSeverely reducedHyperdynamic Mildly enlargedModerately enlargedSeverely enlarged Mild hypokinesisModerate hypokinesisSevere hypokinesisAkinesisDyskinesis Basal inferolateralBasal anterolateralMid-anteriorMid-anteroseptalMid-inferoseptalMid-inferiorMid-inferolateralMid-anterolateralApical anteriorApical septalApical inferiorApical lateralApexNoneDiffuse ASNC imaging guidelines for nuclear cardiology procedures Mildly decreased WTModerately decreased WTSeverely decreased WTHyperdynamic WT Basal anteriorBasal anteroseptalBasal inferoseptalBasal inferolateralBasal anterolateralMid-anteriorMid-anteroseptalMid-inferoseptalMid-inferiorMid-inferolateralMid-anterolateralApical anteriorApical septalApical inferiorApical lateralApexNoneDiffuse New functional abnormalityImprovement of function The information in this table may be repeated as required to describe multiple perfusion defects.
LV, Left ventricular; EF, ejection fraction; EDV, end-diastolic volume; ESV, end-systolic volume; WT, wall thickening.
AbnormalMildly reducedModerately reducedSeverely reduced Mildly enlargedModerately enlargedSeverely enlarged ASNC imaging guidelines for nuclear cardiology procedures Mild hypokinesisModerate hypokinesisSevere hypokinesisAkinesisDyskinesis Basal anteroseptalBasal inferoseptalBasal inferolateralBasal anterolateralMid-anteriorMid-anteroseptalMid-inferoseptalMid-inferiorMid-inferolateralMid-anterolateralApical anteriorApical septalApical inferiorApical lateralApexNoneDiffuse Basal anteroseptalBasal inferoseptalBasal inferolateralBasal anterolateralMid-anteriorMid-anteroseptalMid-inferoseptalMid-inferior ASNC imaging guidelines for nuclear cardiology procedures Mid-inferolateralMid-anterolateralApical anteriorApical septalApical inferiorApical lateralApexNoneDiffuse The information in this table may be repeated as required to describe multiple perfusion defects.
LV, Left ventricular; EF, ejection fraction; FPRNA, first-pass radionuclide angiography; ERNA, equilibrium radionuclide angiocar-diography; EDV, end-diastolic volume; ESV, end-systolic volume; WT, wall thickening.
The report must also function as part of the quality The perfusion imaging study can demonstrate reporting mechanism for the lab. It must include a perfusion data that allow interpretation of perfusion, statement regarding the overall quality of the study and size, and function of the right ventricle (RV). These may should address the presence of potential artifacts, inci- be optionally reported using the data elements in dental findings, and/or extra-cardiac activity that would Table These are usually not routinely reported be pertinent to or limit the quality of the study. These except in the presence of pathology or a specific indi- cation that would warrant their inclusion in the report.
ASNC imaging guidelines for nuclear cardiology procedures Diaphragmatic attenuationMotion artifactSubdiaphragmatic activityMisregistration artifactExtravasated doseCT for attenuation correction Mildly reducedModerately reducedSeverely reduced Moderate hypokinesisSevere hypokinesisAkinesisDyskinesis RV, Right ventricular; FPRNA, first-pass radionuclide angiography; ERNA, equilibrium radionuclide angiocardiography; EF, ejectionfraction, LV, left ventricle; EDV, end-diastolic volume; ESV, end-systolic volume.
ASNC imaging guidelines for nuclear cardiology procedures variables, however, are not covered adequately and arenot assignable to other existing tables. Table FPRNA and ERNA utilize a number of variables describes the variables that are specific for FPRNA and included in other tables, such as those describing LV and RV function at rest and with exercise. A number of Table 14. FPRNA/ERNA (rest and exercise) specific variables where 4 = normal,3 = mild hypokinesis,2 = moderate hypokinesis,1 = severe hypokinesis,0 = akinetic,-1 = dyskinetic SegmentsBasal inferiorBasal anteriorBasal anteroseptalBasal inferoseptalBasal inferolateralBasal anterolateralMid-anterior ASNC imaging guidelines for nuclear cardiology procedures Mid-anteroseptalMid-inferoseptalMid-inferiorMid-inferolateralMid-anterolateralApical anteriorApical septalApical inferiorApical lateralApex RA, Right atrium; LA, left atrium; LV, left ventricle; FPRNA, first-pass radionuclide angiography; ERNA, equilibrium radionuclideangiocardiography; RV, right ventricle.
metabolism mismatched defects must be described withregard to location and Assessment of myocardial viability should include The remaining elements in Table are recom- visual and quantitative analysis. Metabolism defects, mended for use in reporting myocardial viability. The perfusion/metabolism matched defects, and perfusion/ Table 15. Viability—qualitative analysis Basal anteriorBasal anteroseptalBasal inferoseptalBasal inferolateralBasal anterolateralMid-anteriorMid-anteroseptalMid-inferoseptal ASNC imaging guidelines for nuclear cardiology procedures Mid-inferolateralMid-anterolateralApical anteriorApical septalApical inferiorApical lateralApexNone Basal anteroseptalBasal inferoseptalBasal inferolateralBasal anterolateralMid-anteriorMid-anteroseptalMid-inferoseptalMid-inferiorMid-inferolateralMid-anterolateralApical anteriorApical septalApical inferiorApical lateralApexNone Basal anteroseptalBasal inferoseptalBasal inferolateralBasal anterolateralMid-anteriorMid-anteroseptalMid-inferoseptalMid-inferior ASNC imaging guidelines for nuclear cardiology procedures Mid-anterolateralApical anteriorApical septalApical inferiorApical lateralApexNone The information in this table may be repeated as required to describe multiple metabolism defects.
LV,Lleft ventricular; RV, right ventricular.
Table 16. Viability—quantitative analysis use of quantitative image elements (i.e., number of data elements specific to this section are outlined in viable segments and extent of matched and mismatched defects) is also recommended. Table outlines the Furthermore, to ensure timely access to the data, the quantitative data for myocardial viability.
report needs to be compliant with the standard for timely The final component of the structured myocardial reporting requiring completion of the interpretation perfusion report is the most important. The Overall within one business day and transmittal from the lab to Impression assimilates all of the detailed findings pre- the referring physician within two business days.
sented in the prior sections into a succinct statement The appendices to this guideline demonstrate model regarding whether LV perfusion and LV function are formats for structured reporting based on the principles normal or abnormal and describes the abnormality as and data elements contained in this document. Appendix ischemia or infarction. It also addresses the presence or 1 is a model format for stress myocardial perfusion absence of significantly viable myocardium when this imaging and Appendix 2 is a model format for phar- macologic-based myocardial perfusion imaging. They Additionally, the Overall Impression summarizes are intended as examples only and ASNC fully the stress test findings, assesses the clinical significance acknowledges that there are many allowable structured of the scan, and may assign vascular territories to the formats for the reporting of nuclear myocardial perfu- abnormalities and compare results to prior studies. The sion images. Different structured report formats would ASNC imaging guidelines for nuclear cardiology procedures Left anterior descendingRight coronaryLeft circumflexLeft main Potentially viable myocardiumNon-viable myocardium Low riskModerate riskHigh riskUncertain risk LV, Left ventricular; RV, right ventricular; FPRNA, first-pass radionuclide angiography; ERNA, equilibrium radionuclide angiocar-diography; MD, physician or doctor of medicine.
be required for the other indications covered in this document (e.g., PET, exercise/rest FPRNA/ERNA, and C. David Cooke, MSEE, receives partial royalties from the viability imaging). Appendix 3 provides a diagram of sale of Emory Cardiac Toolbox, and is a part-time employee of ASNC imaging guidelines for nuclear cardiology procedures Publication and distribution of this document are made possible by corporate support from Astellas Pharma US, Inc; Covidien; andGE Healthcare. Corporate supporters were not involved in the The overall quality of the study is poor/fair/good/ creation or review of information contained in this guideline.
excellent. Attenuation artifact was present/absent.
Left ventricular cavity is noted to be normal/ enlarged on the rest (and/or stress) studies. There isevidence of abnormal lung activity. Additionally, the Stress/Rest (or Rest/Stress) Single-/Dual- right ventricle is normal/abnormal (specify: ____).
Isotope SPECT Imaging with Exercise Stressand Gated SPECT Imaging SPECT images demonstrate homogeneous tracer distribution throughout the myocardium OR a small/ moderate/large perfusion abnormality of mild/mod- (select one) Diagnosis of coronary disease erate/severe severity is present in the ____ (location) Evaluation of extent and severity of coronary artery region on the stress images. The rest images reveal ____. Gated SPECT imaging reveals normal myo- cardial thickening and wall motion. OR Gated Risk stratification—post-myocardial infarction SPECT imaging demonstrates hypokinesis/dyskin- esis/akinesis of the ____ (location). The left ventricular ejection fraction was calculated to be____% OR the left ventricular ejection fraction was Myocardial perfusion imaging is normal/abnormal.
Previous cardiac procedures include: ____ There is a small/moderate/large area of ischemia/ infarction in the ____ location. Overall left ventric-ular systolic function was normal/abnormal with/ without regional wall motion abnormalities (as The patient performed treadmill exercise/bicycle noted above). Compared to the prior study from exercise using a modified Bruce/Bruce/Naughton/ ____ (date), the current study reveals ____.
____ protocol, completing ____ minutes and com-pleting an estimated workload of ____ metabolicequivalents (METS). The test was terminated due tofatigue/shortness of breath/chest pain/___. The heart rate was ____ beats per minute at baseline and increased to ____ beats at peak exercise, which was ____% of the maximum predicted heart rate. Therest blood pressure was ___ mm/Hg and increased/ Stress/Rest (or Rest/Stress) Single-/Dual- decreased to ___ mm/Hg, which is a normal/ hypotensive/hypertensive response. The patient did/ did not develop any symptoms other than fatigue during the procedure; specific symptoms include____. The resting electrocardiogram demonstrated (select one) Diagnosis of coronary disease ____ and did/did not show ST-segment changes Evaluation of extent and severity of coronary artery consistent with myocardial ischemia.
Myocardial perfusion imaging was performed at rest Risk stratification—post-MI/preoperative/general (____ minutes following the injection of ____ mCi of ____). At peak exercise, the patient was injected with ____ mCi of ____ and exercise was continuedfor ____ minute(s). Gating post-stress tomographic imaging was performed ____ minutes after stress ASNC imaging guidelines for nuclear cardiology procedures Previous cardiac procedures include: ____ ventricular systolic function was normal/abnormal with/without regional wall motion abnormalities (asnoted above). Compared to the prior study from ____ (date), the current study reveals ____.
Pharmacologic stress testing was performed with adenosine/dipyridamole/dobutamine/regadenoson ata rate of ____ for ___minutes. Additionally, low- level exercise was performed along with the vaso- dilator infusion (specify: ____). The heart rate was____ at baseline and rose to ____ beats per minuteduring the adenosine/dipyridamole/dobutamine/rega-denoson infusion. The rest blood pressure was ___mm/Hg and increased/decreased to ___ mm/Hg,which response. The patient developed significant symp-toms, electrocardiogram demonstrated ____ and did/didnot show ST-segment changes consistent with myo-cardial ischemia.
Myocardial perfusion imaging was performed at rest (____ minutes following the injection of ____ mCiof ____). At peak pharmacologic effect, the patientwas injected with ____ mCi of ____. Gating post-stress tomographic imaging was performed ____minutes after stress (and rest).
The overall quality of the study is poor/fair/good/ excellent. Attenuation artifact was present/absent.
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Framingham heart study: A project of the National Heart, Lung

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