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Cardiac Studies

SYNOPTIC - STRUCTURED REPORT - KEY ELEMENTS

• STRUCTURED TEMPLATES

The written report is the final product of the Nuclear Medicine consultation. Reports must contain specific information to identify the patient, the specific procedure, indications for the examination, radiopharmaceutical used and activity administered, route of administration, interval between tracer administration and imaging, succinct technical information about data acquisition and processing (especially the use and dose of additional drugs such as adenosine, CCK, morphine, lasix, etc), specific image and data analysis findings, and a conclusion.

The report should be concise, clear and specific. Standard anatomic designations and physiologic descriptors should be used. Jargon terms, such as "defect" or "photopenia", should not appear in the report. When possible, lesions should be specifically enumerated, physical size measured, and uptake quantified. When lesions are very numerous, the major areas of involvement should be specifically identified. When previous examinations are available, the improvement, progression or stability of disease should be identified. Examples of specific reports are contained with a description of each of the imaging procedures.

• GENERAL STRUCTURE

The following elements should be included in all reports:

Patient identifier: Name, gender, birth date, medical record number 

Date procedure started and date reported

Procedure Title

Indication: Brief statement of clinical problem and question to be answered

Technical factors: Radiopharmaceutical, dose, route of administration, type of scan, interval between injection and imaging, interventions

Reference to prior examination of the same type

Reference to other procedures

Findings: Address clinical question first.

Interpretation: As definitive as possible and avoid repetition of findings.

• GATED BLOOD POOL REST

Clinical Statement: 62 year old woman with breast cancer treated with doxorubicin.

Comparison: Gated scan performed on [date]: LVEF 60%.

Correlation: None

Procedure: Following reinjection of autologous red blood cells labeled with 20 mCi of ^99mTc, planar and SPECT gated images of the cardiac blood pool were recorded.

Findings: The heart is of normal size and configuration, with normal regional wall motion. The left ventricular ejection fraction is 62%.

• GATED BLOOD POOL STRESS

Clinical Statement: A 35-year-old man with lymphoma scheduled for a bone marrow transplant.

Comparison: None.

Correlation: None.

Procedure: Following reinjection of autologous red blood cells labeled with 30 mCi of ^99mTc, gated planar images of the cardiac blood pool were recorded with the patient supine at rest, seated upright on the bicycle ergometer and during the last two minutes of bicycle ergometer stress. The stress procedure was supervised by Dr. [NAME]. Exercise was performed with 25 watt increments every minute.

Findings:

Stress test: The heart rate and blood pressure at rest were 60 BPM and 110/70 mmHg. The patient exercised for a total of 6 minutes, reaching a maximum workload of 100 Watts. Maximum heart rate was 160 BPM, and blood pressure 180/100 mmHg. Exercise was terminated due to leg fatigue. EKG will be reported separately.

Imaging: At rest the right and left ventricles are of normal size and configuration with normal regional and global wall motion, LVEF = 60%. Seated on the bicycle or ergometer at rest, the LVEF = 65%. During exercise LVEF increased to 70%.

• REST/REDISTRIBUTION ²⁰¹Tl-Chloride

Clinical statement: A 55-year-old diabetic hypertensive man had transient ST changes and a slightly elevated troponin.

Comparison: None.

Correlation: Contrast CT coronary angiography revealed 50-70% stenoses in the mid LAD and proximal Circumflex. The RCA had no significant narrowings.

Procedure: Following intravenous administration of 4 mCi of ²⁰¹Tl-Chloride, two sets of gated SPECT images of the heart were recorded: the first acquisition commenced about 5 minutes after injection, and the second acquisition was performed about 6 hours after injection.

Findings: The initial images demonstrate a small area of decreased perfusion involving the inferior and lateral walls, with decreased regional wall motion. The delayed images demonstrate improvement in the relative concentration of ²⁰¹Tl, with persistence of the regional wall motion abnormality.

• STRESS - REINJECTION ²⁰¹Tl-Chloride

Clinical statement: A 65-year-old diabetic hypertensive man with a strong family history of CAD.

Comparison: None.

Correlation: Coronary calcium score of 1500.

Procedure: Following intravenous administration of 4 mCi of ²⁰¹Tl-Chloride at peak stress, gated SPECT images of the heart were recorded. Acquisition commenced about 5 minutes after injection. When the patient returned about 4 hours later, an additional 1 mCi of ²⁰¹Tl-Chloride was injected and gated SPECT images were recorded about 20 minutes later.

Findings:

Stress: The patient exercised for 8 minutes on the Bruce protocol, achieving a workload of 9 METS. The resting heart rate and blood pressure were 72 BPM, 105/70 mmHg respectively. At peak exercise, the heart rate was 145BPM (92% of predicted maximum) and blood pressure 200/110 mmHg (rate pressure product 29,000). The patient had no complaints during the procedure. EKG will be reported separately.

Images: Immediate post-stress images demonstrate a small area of moderately decreased perfusion involving the inferior and lateral walls, with decreased regional wall motion. Normal perfusion is seen in the right ventricular myocardium. The reinjection images demonstrate improvement in the relative concentration of ²⁰¹Tl in the inferior and lateral walls, with improvement of the regional wall motion abnormality. LVEF at stress is 58%.

• STRESS/REST MYOCARDIAL PERFUSION SCAN

Clinical statement: A 65-year-old diabetic hypertensive woman with a strong family history of CAD.

Radiopharmaceutical: ^99mTc-Tetrofosmin (or ^99mTc-Sestamibi) 10 mCi i.v. at rest and ^99mTc-Tetrofosmin (or ^99mTc-Sestamibi) 30 mCi i.v. at stress.

Comparison: None.

Correlation: Coronary calcium score 1500.

Procedure:

Rest: Following intravenous administration of 10 mCi of ^99mTc-Tetrofosmin at rest, gated SPECT images of the heart were recorded.

Mode of stress: [treadmill/pharmacologic]

Stress imaging: [XX] minutes following injection of [30] mCi of ^99mTc-Tetrofosmin, gated SPECT attenuation corrected images of the heart were recorded.

Findings:

Stress test: The patient exercised for [XX] minutes on the Bruce protocol, achieving a workload of [XX] METS. The resting heart rate and blood pressure were [XX], [XX] respectively. At peak exercise, the heart rate was [XX] and blood pressure [XX]. Exercise was terminated due to [fatigue/dyspnea/chest pain]. The patient had no complaints during the procedure.

Scan findings: The post-stress images demonstrate a small area of decreased perfusion involving the inferior and lateral walls, with decreased regional wall motion. Normal perfusion is seen in the right ventricular myocardium. The rest injected images demonstrate improvement in perfusion of the inferior wall, with improvement of the regional wall motion abnormality. The left ventricular chamber is [normal/dilated]. LVEF at stress is [XX]%.

• STRESS/REST DUAL TRACER MYOCARDIAL PERFUSION SCAN

Clinical statement: A 65-year-old diabetic hypertensive woman with a strong family history of CAD.

Radiopharmaceutical: ²⁰¹Tl-Chloride 4 mCi i.v. at rest and ^99mTc-Tetrofosmin (or ^99mTc-Sestamibi) 30 mCi i.v. at stress.

Comparison: None.

Correlation: Coronary calcium score 1500.

Procedure:

Rest: Following intravenous administration of 4 mCi of ²⁰¹Tl-Chloride at rest, gated SPECT images of the heart were recorded.

Mode of stress [treadmill/pharmacologic]

Stress imaging: [XX] minutes following injection of [30] mCi of ^99mTc-Tetrofosmin, gated SPECT attenuation corrected images of the heart were recorded.

Findings:

Stress test: The patient exercised for [XX] minutes on the Bruce protocol, achieving a workload of [XX] METS. The resting heart rate and blood pressure were [XX], [XX] respectively. At peak exercise, the heart rate was [XX] and blood pressure [XX]. Exercise was terminated due to [fatigue/dyspnea/chest pain]. The patient had no complaints during the procedure.

Scan findings: The post-stress images demonstrate a [small/medium/large] area of [mild/moderate/severe] decreased perfusion involving the inferior and lateral walls, with decreased regional wall motion. Normal perfusion is seen in the right ventricular myocardium. The rest injected images demonstrate improvement in perfusion of the inferior wall, with improvement of the regional wall motion abnormality. The left ventricular chamber is [normal/dilated]. LVEF at stress is [XX]%.

• Rubidium-82 MYOCARDIAL PERFUSION

Clinical statement: [XX] year old [man/woman] with [cardiac risk factors of hypertension, hyperlipidemia, diabetes, known coronary artery disease].

Comparison: [<None>]

Correlation: [<None>]

Technique: A prospectively gated CT was recorded for coronary calcium scoring followed by a low dose CT for attenuation correction. Gated list mode data was recorded for 7 minutes beginning with infusion of [30] mCi ⁸²Rb to determine myocardial perfusion at rest. Pharmacologic stress was performed with [dipyridamole, 0.140 mcg/kg/min i.v. for 4 minutes] [regadenoson 0.4mg i.v. over 20 seconds]. Gated list mode data was recorded for 7 minutes beginning with infusion of [30] mCi ⁸²Rb to determine myocardial perfusion at stress.

The stress procedure was supervised by Dr. [XX]. The images and EKG were reviewed with Dr. [XX]. EKG will be reported separately.

Findings:

Stress response: Baseline HR [XX], BP [XX]; peaks stress HR [XX], BP [XX]. The patient was [<asymptomatic>] during stress.

Left ventricular size: [<Normal>]

Perfusion: [Homogeneous/if lesion present give location – anterior inferior septal lateral/describe size small medium large and severity]

Regional wall motion: [<Normal>]

LVEF: [XX]% at rest and [XX]% at stress

Coronary calcium score: [XX.]

Increase in relative risk with increasing coronary artery calcium scores in asymptomatic persons:

calcium score               1 -- 100                       relative risk 1.9

calcium score               100 -- 400                  relative risk 4.3

calcium score               400 to 1000               relative risk 7.2

calcium score               >1000                        relative risk 10.8

low risk equals less than 1% per year

intermediate risk equals 1 to 2% per year

high risk equals greater than 2% per year

Oudkerk et al Eur Radiol 2008; 18:2785-2807