Education
At the end of general clinical training each cardiology fellow will be competent in the performance, analysis, and interpretation of nuclear cardiology procedures and will meet level II criteria for specialized training in nuclear cardiology as defined by the American College of Cardiology (COCATS Task Force 5) and American Society of Nuclear Cardiology.
Nuclear Cardiology Curriculum
Basic Physics and Instrumentation
Aim:
Understand basic physics of radioactivity
Understand methods of detection of radiation
Be familiar with basic imaging instrumentation technology, principles, and methods including single/multi crystal cameras, single photon emission tomography (SPECT) and planar imaging quantitation principles, image procession, and ECG-gating principle
Method:
Biannual radiation safety and physics course.
Each fellow spends four to six 4-week periods on the Nuclear Cardiology rotation. During this time, fellows will participate in hand-on image processing under the supervision of Nuclear Cardiology technologists and Nuclear Cardiology Attendings.
Directed reading:
Clinical Nuclear Cardiology. Bellow GA. Chapter 1. Instrumentation in Nuclear Cardiology
Radiopharmaceuticals
Aim:
Understand Thallium-201 kinetics
Understand Tc99m sestamibi kinetics
Be familiar with kinetics and characteristics of Tc99m tetrafosmin, Tc99m teboroxine, Tc99m pyrophosphate, Indium-111 antimyosin antibodies, positron emitting radionuclides, I-123 MIBG, Iodine labeled fatty acids
Methods:
Biannual radiation safety and physics course.
Each fellow spends four to six 4-week periods on the Nuclear Cardiology rotation. During this time, clinically pertinent facts related to radiopharmaceuticals will be discussed on the daily 1-2 hour reading session.
Directed reading:
Clinical Nuclear Cardiology. Beller GA. Chapter 2. Radiopharmaceuticals in Nuclear Cardiology.
Detection of Coronary Artery Disease (CAD)
Aim:
Understand principles of sensitivity, specificity, predictive value and Bayes’ Theorem
Understand principles of limitations of exercise electrocardiography for the diagnosis of coronary artery disease
Understand principles and value of stress thallium-201 myocardial perfusion imaging (MPI) for detection of coronary artery disease
Understand principles and values of stress Tc99m sestamibi myocardial perfusion imaging for the detection of coronary artery disease
Identify normal and abnormal myocardial perfusion imaging studies
Distinguish between transient, partially transient, and fixed perfusion defects on myocardial perfusion imaging
Understand advantages, disadvantages of SPECT imaging as it relates to detection of coronary artery disease
Understand causes of false positive imaging studies
Identify various imaging protocols for using thallium-201 and Tc99 sestamibi for myocardial perfusion imaging
Identity normal and abnormal global and regional right and left ventricular contractile function.
Distinguish mild, moderate, and severe regional and global right and ventricular contractile function.
Identify arterial territories that correspond to perfusion defects seen on planar or SPECT myocardial perfusion imaging
Understand principles and use of exercise radionuclide ventriculography for detection of coronary artery disease
Method:
Each fellow spends four to six 4-week periods on the nuclear cardiology rotation. During this time, fellows will participate in interpretation of all nuclear cardiology imaging studies under direct supervision of nuclear cardiology and nuclear medicine attending physicians. During this time, fellows will participate in discussions with Nuclear Cardiology and Nuclear Medicine Attendings, addressing the diagnostic implications of imaging results.
CORE Lecture Series.
Myocardial perfusion imaging for the diagnosis of coronary artery disease.
Directed reading
Clinical Nuclear Cardiology - Beller GA. Chapter 3. Detection of Coronary Artery Disease.
Assessment of Prognosis
Aim:
Understand primary determinates of prognosis in coronary artery disease
Understand principles and limitations of stress ECG for risk-stratification
Understand rationale and advantages of myocardial perfusion imaging for risk-stratification
Identify scintigraphic imaging variables associated with low and high risk of cardiac events
Understand prognostic value of myocardial perfusion imaging for patients with known or suspected coronary artery disease, post-myocardial infarction, and for pre-operative cardiac evaluation
Understand principles and use of exercise and resting radionuclide ventriculography for assessment of cardiac risk
Method:
Each fellow spends four to six 4-week period on the Nuclear Cardiology rotation. In addition, fellows participate in discussions with Nuclear Cardiology and Nuclear Medicine Attendings to address the prognostic implications of imaging results during interpretation of Nuclear Cardiology imaging studies in the daily reading sessions.
CORE Lecture Series:
Prognostic value of myocardial perfusion imaging in patients with known or suspected coronary artery disease; Risk stratification of patients with acute myocardial infarction; Detection of cardiac risk in patients undergoing non-cardiac surgery.
Directed reading:
Beller GA, Chapter 4, Radionuclide Assessment of Prognosis. Clinical Nuclear Cardiology.
Brown KA, Prognosis value of myocardial perfusion imaging: State-
of-the-art and new developments. J Nucl Cardiol 1996; 3:516-537.
Brown KA. Prognosis value of radionuclide cardiac imaging. Gerson MC. Ed. Cardiac Nuclear Medicine. McGraw Hill, New York, 1997.
Brown KA. Risk assessment in CAD: Suspected CAD/Known Stable CAD. In: Iskandrian AE, Verani MS. Nuclear Cardiac Imaging Principles and Applications, 3rd Edition. (In press).
Brown KA. Nuclear Cardiology. In: Theroux P. Acute Coronary Syndromes: A Companion to Braunwald's Heart Disease. Harcourt Publishing (In press).
Pharmacologic Stress Imaging
(see also Exercise Stress Testing - vasodilator stress)
Aim:
Understand principles and rationale for use of vasodilator stress myocardial perfusion imaging
Understand hemodynamic effects, mechanism of action of dipyridamole and adenosine
Identify clinical imaging protocols with the use of dipyridamole and adenosine with myocardial perfusion imaging
Understand principles and rationale for use of dobutamine stress with myocardial perfusion imaging.
Understand sensitivity, specificity of vasodilator stress myocardial perfusion imaging for detection of coronary artery disease
Understand value and use of vasodilator myocardial perfusion imaging for cardiac risk stratification.
Identify normal and abnormal myocardial perfusion imaging studies
Distinguish between normal uptake, transient, partially transient, and fixed defects
Distinguish between low risk and high risk imaging studies
Method:
Each fellow will spend four to six 4-week periods on the nuclear cardiology rotation. During this time, fellows participate in discussions with Nuclear Cardiologist and Nuclear Medicine Attending physician relative to technique, use, and value of pharmacologic stress myocardial perfusion imaging for detection of coronary artery disease and cardiac risk assessment.
CORE Lecture Series
Prognostic value of myocardial perfusion imaging – patients with known or suspected coronary artery disease. Risk stratification of patients with acute myocardial infarction; determination of cardiac risk in patients undergoing non-cardiac surgery.
Directed reading:
Clinical Nuclear Cardiology – Beller GA, Chapter 8, Pharmacologic Stress Imaging.
Integration of Clinical, Stress and Radionuclide Cardiac Imaging Data for Final Interpretation
Acquisition of:
Knowledge of kinetics of uptake of radionuclide tracers that influence timing of injection and imaging
Knowledge of advantages and disadvantages of different perfusion agents
Knowledge of physiology of exercise or pharmacologic stress that influences timing of stress and injection of radionuclide perfusion agent
Knowledge of diagnostic information that stress radionuclide cardiac imaging adds to exercise testing
Knowledge of sensitivity/specificity of stress radionuclide cardiac imaging for diagnosis of coronary artery disease
Knowledge of improvement in diagnostic accuracy for coronary artery disease compared to exercise testing
Knowledge of integration of perfusion and function results
Knowledge of relationship of imaging results to presence or absence of myocardial viability
Knowledge of prognostic value of stress radionuclide cardiac imaging in ischemic and non-ischemic heart diseases
Knowledge of impact of extent and severity of perfusion defects and reversibility on prognostic implications of imaging results in ischemic heart disease
Knowledge of how to apply Bayes’ theorem to test results
Knowledge of factors involved with generating pre-imaging probability of coronary artery disease (including age, gender, symptomatology, and stress ECG results)
Knowledge of impact of levels of stress, medications, and timing of perfusion agent injection on diagnostic sensitivity/specificity of imaging results
Knowledge of improvement in diagnostic and prognostic value with radionuclide cardiac imaging compared to exercise testing
Method:
Each fellow will spend four to six 4-week periods on nuclear cardiology rotations. During this time, fellows will participate in discussions with Nuclear Cardiologists addressing the integration of clinical, stress and radionuclide cardiac imaging data for final interpretation
Directed reading:
Cardiac Nuclear Medicine. Gerson, MC. Chapter 20. Test accuracy, test selection, and test result interpretation in chronic coronary artery disease.
Assessment of Myocardial Viability
Aim:
Distinguish between hibernating and stunned myocardium
Understand basis for using myocardial perfusion imaging for detection of myocardial viability
Identify viable and non-viable myocardium using thalliuim-201 imaging in ECG-gated Tc99m sestamibi myocardial perfusion imaging
Identify imaging protocols for the use of thallium-201 for detection of myocardial viability, including rest-delayed imaging, re-injection protocols, and late post-stress imaging
Understand potential role of iodinated fatty acid imaging for detection of myocardial viability
Understand role of infarct imaging with radiolabeled myosin specific antibody
Understand role and principles of PET imaging for detection of myocardial viability
Methods:
Each fellow spends four to six 4-week periods on the nuclear cardiology rotation. During this time, fellows will participate in discussions with Nuclear Cardiology and Nuclear Medicine Attendingsto address to the use of radionuclide technique for detection of myocardial viability.
CORE Lecture Series. Role of myocardial perfusion imaging of myocardial viability.
Directed reading:
Clinical Nuclear Cardiology – Beller GA, Chapter 9, Assessment of Myocardial Viability.
Assessment of Ventricular Function
Aim:
Understand principle of ECG-gated imaging acquisition
Understand principle of first pass radionuclide ventriculography
Understand advantages of radionuclide techniques for assessment of ventricular function
Understand principles of equilibrium radionuclide ventriculography
Understand principles of gated SPECT myocardial perfusion imaging
Distinguish normal from abnormal global and regional ventricular function on equilibrium radionuclide ventriculography, ECG-gated Tc99 sestamibi SPECT myocardial perfusion imaging, and gated first pass radionuclide ventriculography
Calculate ejection fractions from gated first pass, equilibrium radionuclide ventriculography, and gated SPECT myocardial perfusion imaging
Method:
Each fellow spends four to six 4-week periods on the Nuclear Cardiology rotations. During this time fellows participate in interpretation of gated first pass and equilibrium radionuclide ventriculograms and ECG gated Tc99m sestamibi SPECT myocardial perfusion imaging and participate in discussions related to the use of these techniques under supervision of Nuclear Cardiology and Nuclear Medicine Attendings. In addition, each fellow participates in analysis of ventricular function with the use of radionuclide techniques.
Directed reading:
Nuclear Cardiology – Zaret and Beller, Section III, Assessment of Ventricular Function.
Interpretation and Reporting of Imaging Results
Acquisition of:
Knowledge of computer display, systems, standard formats for display of images (SPECT and planar), normalization of images
Knowledge of technical sources of error (including motion, attenuation, adjacent/overlap uptake, reconstruction and count statistic artifacts), ability to recognize such errors and correct them
Knowledge of image interpretation including ventricular size, lung uptake (thallium-201 imaging), perfusion defect assessment (location, extent, severity, reversibility), non-cardiopulmonary findings, and integration of findings into final interpretation
Knowledge of gated SPECT display, quality control and interpretation of regional and global ventricular function
Knowledge of quantitative image analysis
Knowledge of coronary anatomy and relation to cardiac images
Knowledge of normal global and regional function, the physiologic determinants of these characteristics, and the potential pathophysiologic causes of ventricular dysfunction
Knowledge of reporting systems and ability to generate a coherent meaningful report which maximizes clinical utility
Methods:
Each fellow spends four to six 4-week periods on the nuclear cardiology rotations. During this time fellows participate in discussions with Nuclear Cardiology and Nuclear Medicine Attendings to address interpretation and reporting of imaging results.
