Advertisement

Journal of Nuclear Cardiology

, Volume 24, Issue 6, pp 2064–2128 | Cite as

ASNC imaging guidelines for nuclear cardiology procedures

Standardized reporting of nuclear cardiology procedures
  • Peter L. Tilkemeier
  • Jamieson Bourque
  • Rami Doukky
  • Rupa Sanghani
  • Richard L. Weinberg
ASNC Standardized Reporting Guidelines

Abbreviations

AUC

Appropriate use criteria

CAD

Coronary artery disease

ECG

Electrocardiogram

LV

Left ventricular

LVEF

Left ventricular ejection fraction

METS

Metabolic equivalents

MPHR

Maximal predicted heart rate

PET

Positron emission tomography

RV

Right ventricle

SPECT

Single-photon emission computed tomography

Introduction

The American Society of Nuclear Cardiology (ASNC) published a guideline for the reporting of myocardial perfusion imaging (MPI) in 2009.1 Over the last eight years there has been significant change in the breadth and depth of nuclear cardiology practice along with significant changes in the landscape of structured reporting. In consideration of this degree of change, it is appropriate that the guideline be updated and expanded to include a broader perspective of nuclear cardiology practice. At the same time, many things have not changed. This includes the fact that the report should provide a basic “bottom line” result to the referring physician and that this result must be clear and concise.2-4 This premise was expanded on by the American College of Radiology (ACR) with its development of a reporting and communication guideline with continued recent updates.5 All these documents emphasized the need for a defined structure containing standardized data elements to facilitate utilization of the complex data contained in an imaging report into the integrated healthcare of the patient through the electronic health record. The structured report is also an integral part to define quality in nuclear cardiology practices . There continues to be interest in the implementation of structured reporting as a mechanism to improve quality and outcomes and to reduce cost in fulfillment of the triple aim.

Since the publication of the prior guideline there have been significant developments in the field of nuclear cardiology. Examples of this include the development of the ImageGuideTM Registry by ASNC, the development of additional registries for imaging internationally, the expansion of nuclear cardiology into greater utilization of positron emission tomography (PET) imaging, and new protocols for imaging inflammation, viability, and innervation.6 These additional areas of interest will be addressed in this updated guideline for nuclear cardiology procedure reporting in contrast to the prior document that was limited to perfusion imaging only.1 There is also new emphasis on the concept of interpreting the interpretation. Research regarding this important aspect of result utilization has focused on how the referring physician incorporates the report data to affect care and the differences between the referring physicians approach and the imaging physicians anticipated response to the report.7 This will become an increasingly important area of information science in the future. To help meet the needs of the referring physician, the appearance of a standardized report can and should vary from user to user. There should not be a single standard appearance of a report but one that best conveys the content to the end user. This may be in paragraph form for some laboratories while others might use a table or even a list of structured data elements. All would meet the guidelines for structured reporting as they are derived from defined structured data elements as outlined in this guideline.1,8

An essential part of structured reporting is the ability to use and incorporate other standards to facilitate data sharing among many different sources. These standards include the Digital Imaging and Communications in Medicine (DICOM) and the Integrating the Healthcare Enterprise (IHE) standards. The DICOM standard for stress reporting includes the data elements for structured nuclear cardiology reporting.9,10 The use of the DICOM elements has been integral to the clinical implementation of reporting software by both developers and manufacturers. This is supported through the utilization of the IHE standards for communication of data among different vendor systems and single and multimodality imaging environments.11,12 The data from this new IHE standard have been incorporated into this document.

Two important documents were utilized in the development of the first nuclear cardiology myocardial perfusion imaging reporting standard and remain important and relevant today. The American College of Cardiology (ACC) “Health Policy Statement on Structured Reporting and Cardiovascular Imaging” and the “Key Data Elements and Definitions for Cardiac Imaging: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards” remain as sentinel documents and facilitate the reporting of imaging studies in multimodality environments.13,14 In addition to the ACC documents, the European Association of Nuclear Medicine and the European Association of Cardiovascular Imaging have published a guideline regarding reporting nuclear cardiology.15 This important guideline addresses an update to the standards and serves as a guidepost as we move forward to standardized structured reporting internationally. The development of the ImageGuideTM Registry for myocardial perfusion imaging has also been the cause for some redefinition of the data elements that were present in the prior version of the myocardial perfusion imaging study reporting standard. This updated image reporting guideline incorporates and harmonizes the recommendations of all these guidelines and unifies ASNC documents that have been published since the prior reporting guideline.

As with the prior document, this guideline consists of tables composed of the variables, their description (i.e., text, numeric, date), priority (i.e., required, recommended, or optional), and the allowed response(s). With regards to the allowed responses to numerical values, the writing group acknowledges that different units of measurement can be used to express the same value, such as millicuries (mCi) and megabecquerels (MBq). As this guideline is intended for international use, both traditional English units of measure and their metric equivalents are acceptable responses. It is required, however, that the user be consistent throughout the report regarding the system of units utilized. Acceptable units of measure are outlined in Appendix 1. As the structured report may be used to populate data in registries, such as ImageGuide™, it is a requirement of the registry submission process to provide the appropriate conversion factors from the structured report data to assure compliance with the allowed format from the registry’s data dictionary. Finally, examples of sample structured reports from numerous laboratories around the United States are incorporated in the appendix as a resource for the reader.

As was noted in the prior document, ASNC continues to support the mandatory use of structured reporting as a mechanism to improve the communication and reporting of nuclear cardiology reports. This has begun to be incorporated into the laboratory accreditation process, and there has been significant improvement over the course of eight years. There remain significant areas for improvement, particularly with regards to defect size and severity, and consistent reporting of these important variables.16 This guideline is designed to provide imaging physicians and technologists the necessary information to report nuclear cardiology procedures in a structured format using standardized data elements. While the content of the document has been carefully reviewed by many experts, the document should not be considered as a source of medical advice or professional service.

Table of Contents for Structured Data Elements

Site administrative data

Table 1

Study demographics

 

 Patient demographics and study referral data

Table 2

 Clinical Information

Table 3

Appropriate use reporting

 

Study description

 

 Stress testing data

Table 4

 Resting ECG data

Table 5

 Stress ECG data

Table 6

Imaging data

 

 Imaging parameters

Table 7

 Additional imaging parameters specific to viability studies

Table 8

 Imaging parameters specific for inflammation/infection

Table 9

 Imaging parameters for Tc-99m PYP

Table 10

 Qualitative LV perfusion assessment (SPECT and PET)

Table 11

 Quantitative LV perfusion assessment (SPECT and PET)

Table 12

 LV gated function volume assessment at stress

Table 13

 LV gated functional and volume assessment at rest

Table 14

 Additional PET-specific LV perfusion and function parameters

Table 15

 Right ventricular perfusion and function parameters

Table 16

 Miscellaneous data

Table 17

 FPRNA/ERNA (rest and exercise)

Table 18

 Viability—qualitative analysis

Table 19

 Viability—quantitative analysis

Table 20

 Inflammation/Infection—qualitative parameters

Table 21

 Inflammation/Infection—quantitative parameters

Table 22

 mIBG analysis parameters

Table 23

 Tc-99m PYP analysis parameters

Table 24

 Coronary artery calcium score analysis parameters

Table 25

Overall impression

Table 26

Combined conclusion

Table 27

Comparison to prior studies

Table 28

ImageGuide Registry CMS reported performance measures

Table 29

ECG, electrocardiographic; LV, left ventricular; RV, right ventricular; FPRNA, first-pass radionuclide angiography; ERNA, equilibrium radionuclide angiocardiography

Structured Reporting

Components of the Report

According to the ‘‘Health Policy Statement on Structured Reporting in Cardiovascular Imaging,”13 the standard components of a report include the following major headings: Administrative Information, Patient Demographics, Study Referral Data, History and Risk Factors, Study Description, Study Findings, and other reporting parameters. These elements are outlined in detail in ‘‘Key Data Elements and Definitions for Cardiac Imaging: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards,”14 which addresses specific details for each of these major headings for multiple cardiac imaging modalities and these remain unchanged from the prior document.

A few of the general data elements, and many of the specific data elements, may be recorded at the time that the test is performed. Some elements may not be required in the final report. This may be the case for some fields that are required for quality reporting, but not necessarily for reporting the findings from an individual 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, reporting the data to registries, and other reports as needed. The greatest strength to structured data utilization is the ability to generate multiple report formats with varying levels of detail depending on the clinical or administrative need.

This document will harmonize these generalized concepts and apply them specifically to nuclear cardiology. Due to the variability of the study types encompassed by this document, some of the data elements are specific to certain types of acquisitions, or are dependent upon the study indication (e.g., viability determination by PET imaging). Therefore, some data elements may be required for certain acquisitions and clinical indications, while some may be optional or perhaps irrelevant for other indications.

A number of the data elements contained in the tables have been derived from, and harmonized with, other guideline documents, some multisocietal and others ASNC-specific.3,4,17-21 This update also addresses additional modalities that were not included in the prior versions of the document, such as: broader treatment of PET and viability, and non-perfusion imaging including amyloid detection, inflammation/infection, MIBG in heart failure and coronary calcium scoring, and its incorporation into the nuclear cardiology report. The data elements required for reporting the additional modalities have been added to specific tables where appropriate or additional tables have been added to the document to cover those items that were specific to the modality and could not be generalized to one of the existing table headings. Finally, a perspective on the future direction of nuclear cardiology reporting has been included as a guidepost for the future.

Site Administrative Data

The Site Administrative Data section of the report is the descriptor of the site performing the study. It includes elements such as the physical address, accreditation status, type of facility (e.g., hospital or office), and insurance payer. These data may only need to be collected as part of the reporting process, and some elements may not be recorded in the final report. Some elements may be necessary to inform registry submission of the data and as part of the quality initiatives as we transition from volume-to-value-based practice (Table 1).
Table 1

Site administrative data

Variable

Description

Datatype

Priority

Response

Site ID

Site ID for national identification

Numerical

Required

XXXXXX

Site of service

Type of facility

Text

Optional

Hospital—inpatient

Hospital—outpatient

Non-hospital—inpatient

Non-hospital—outpatient

Mobile-based—inpatient

Mobile-based—outpatient

Practice/hospital name

Name of practice or hospital

Text

Required

Variable

Location of imaging study

Imaging facility address

Text

Required

Variable

Imaging facility phone number

Imaging facility phone number

Numerical

Recommended

XX-XXX-XXX-XXXX

Accreditation status

Accreditation status of facility

Text

Recommended

Yes

No

Application submitted

Accreditation entity

Accreditation entity

Text

Recommended

ACR

IAC Nuclear/PET

TJC

RadSite

Other

ID, identification; ACR, American College of Radiology; IAC Nuclear/PET, Intersocietal Accreditation Commission Nuclear/PET; TJC, The Joint Commission

Patient Demographics and Study Referral

The Patient Demographics and Study Referral data section provides the clinical indications for the study, information regarding the referring and interpreting provider in addition to the necessary demographic information that could impact the clinical outcomes of the study. Indications to be considered include the following major areas: diagnosis of coronary artery disease (CAD), extent and severity of known CAD, risk stratification including peri-operative risk, determination of viability, assessment of acute chest pain syndromes, evaluation of structural heart disease, and heart failure. The table also allows for a secondary indication to be selected. With the inclusion of the History and Risk Factors section, this would complete the data elements contained in Tables 2 and 3.
Table 2

Patient demographics and study referral data

Variable

Description

Datatype

Priority

Response

GUID

Globally unique identifier

Text

Required

36 positions (32 digits plus 4 dashes) (0–9 and a–f) e.g., d28d6188-41e8-47f6-b0b9-3a2b36377c61

MRN

Medical record number

Alphanumeric

Required

 

Patient DOB

Date of birth

Numerical

Required

mm/dd/yyyy

Patient zip code

Zip code for home address

Numerical

Recommended

XXXXX

Other (e.g., International zip code)

Sex

Patient gender at birth

Text

Recommended

Male

Female

Unknown

Patient hospitalized

Patient status at time of study

Text

Optional

Ambulatory

Inpatient

Observation/ER

Study completion date and time

Imaging component completed

Date/Time

Required

mm/dd/yyyy

hh:mm

First name

Patient first name

Text

Required

Variable

Last name

Patient last name

Text

Required

Variable

Weight

Patient weight

Numerical

Required

Value in units (XXX.XX)

Height

Patient height

Numerical

Required

Value in units (XXX.XX)

Chest circumference

Chest circumference

Numerical

Optional

Value in units (XXX.XX)

Bra cup size

Bra cup size

Text

Optional

Variable

Ethnicity

Ethnic origin

Text

Recommended

Hispanic or Latino

Not Hispanic or Latino

Race

Patient race (multi-select)

Text

Optional

American Indian/Alaskan native

Asian

Black/African American

Native Hawaiian/Pacific Islander

White

Insurance payer

Insurance payer for current study (multi-select)

Text

Recommended

Indian Health Service

Medicaid

Medicare

Medicare advantage

Military healthcare

Non-US insurance

Private health insurance

State-specific plan (non-Medicaid)

None

Referring provider first name

Referring provider first name

Text

Recommended

Variable

Referring provider middle name

Referring provider middle name

Text

Recommended

Variable

Referring provider last name

Referring provider last name

Text

Required

Variable

Referring provider NPI number

Referring provider NPI number

Numeric

Recommended

XXXXXXXXXX

Interpreting provider first name

Interpreting provider first name

Text

Required

Variable

Interpreting provider middle name

Interpreting provider middle name

Text

Recommended

Variable

Interpreting provider last name

Interpreting provider last name

Text

Required

Variable

Interpreting provider NPI number

Interpreting provider NPI number

Numeric

Required

XXXXXXXXXX

Quantitative package provider

Quantitative software manufacturer used to process study

Text

Optional

Cedars-Sinai

Digisonics

GE

Generic

INVIA

Philips

Positron

Siemens

Syntermed

Other

Interpreting MD board certification

Name of board

Text

Optional

Cardiovascular disease

Radiology

Nuclear medicine

Other

None

Physician subspecialty certification

Name of certifying board

Text

Optional

CBNC

ABNM

ACR certificate of added qualification

Interpretation date and time

Date of interpretation

Date/Time

Required

00/00/0000

hh:mm

Signature date and time

Date of transcription

Date/Time

Required

00/00/0000

hh:mm

DOB, date of birth; GUID, Globally Unique Identifier; ID, identification; MD, physician or doctor of medicine; MRN, medical record number; CBNC, Certification Board of Nuclear Cardiology; ABNM, American Board of Nuclear Medicine; ACR, American College of Radiology

Table 3

Clinical information

Variable

Description

Datatype

Priority

Response

Primary indication

Primary study indication

Text

Required

Abnormal electrocardiogram

Abnormal stress test

Angina or angina equivalent

Arrhythmia

Assessing functional significance of known CAD

Assessment of symptoms with suspected cardiac etiology

Assessment of ventricular function

Cardiac morphology (including cardiac mass)

Chest pain

Claudication

Congenital heart disease

Coronary artery disease*

Coronary risk factors

Dyspnea/SOB

Evaluation for cardiomyopathy

Evaluation for valvular heart disease

Heart failure

History of CABG

History of PCI

Hypertension

Hypotension

Initial detection/risk assessment of CAD

Palpitations

Pericardial disease

Preoperative evaluation within 30 days preceding low-risk non-cardiac surgery

Preoperative evaluation within 30 days preceding non-cardiac surgery. (Note: If this value is selected, also note the type of non-cardiac surgery.)

Syncope

Viability

Not provided

Other (If this value is selected, complete the Other text field.)

Secondary indication

Secondary study indication(s) (multi-select)

Text

Required

Abnormal electrocardiogram

Abnormal stress test

Angina or anginal equivalent

Arrhythmia

Assessing functional significance of known CAD

Assessment of symptoms with suspected cardiac etiology

Assessment of ventricular function

Cardiac morphology (including cardiac mass)

Chest pain

Claudication

Congenital heart disease

Coronary artery disease

Coronary risk factors

Dyspnea/SOB

Evaluation for cardiomyopathy

Evaluation for valvular heart disease

Heart failure

History of CABG

History of PCI

Hypertension

Hypotension

Initial detection/risk assessment of CAD

Palpitations

Pericardial disease

Preoperative evaluation within 30 days preceding low-risk non-cardiac surgery

Preoperative evaluation 30 days preceding non-cardiac surgery. (If this value is selected, also note the type of non-cardiac surgery.)

Syncope

Viability

Not provided

Other (if this value is selected, complete the Other text field.)

Pretest chest pain

Type of chest pain

Text

Required for perfusion viability otherwise recommended

Typical angina

Atypical angina

Non-anginal chest pain

Anginal equivalent

No chest pain

Medications

Medications (multi-select)

Text

Recommended

ACE/ARB

Aminophylline or theophylline

Antiarrhythmics

Anticoagulant

Aspirin, other antiplatelet agents

Beta blocker

Ca++ blocker

Diabetic medications

Digoxin

Dipyridamole

Diuretics

Erectile dysfunction medication

Inhaler

Lipid-lowering agents

Metformin

Neprilysin inhibitor

Nitrates

Other anti-hypertensives

Ranolazine

None

Test medications

Medications taken on day of test (multi-select)

Text

Recommended

ACE/ARB

Aminophylline or theophylline

Antiarrhythmics

Anticoagulant

Aspirin, other antiplatelet agents

Beta blocker

Ca++ blocker

Diabetic medications

Digoxin

Dipyridamole

Diuretics

Erectile dysfunction medication

Inhaler

Lipid-lowering agents

Metformin

Neprilysin inhibitor

Nitrates

Other anti-hypertensives

Ranolazine

None

Cardiac risk factors

Risk factors (multi-select)

Text

Recommended

Chronic kidney disease

Diabetes

Erectile dysfunction

Family history

Hypercholesterolemia

Hypertension

Metabolic syndrome

Obesity

Obstructive Sleep Apnea

Peripheral vascular disease

Smoking

Cardiac history

Cardiac history (multi-select)

Text

Recommended

s/p PCI/stent

s/p CABG

s/p MI

History of peripheral vascular disease

Arrhythmia

Heart failure

s/p heart transplant

Other

Risk score patients without chest pain

Calculated risk score

Text

Optional

Low (<10% 10-year risk)

Intermediate (10%–20% 10-year risk)

High (>20% 10-year risk or a coronary risk equivalent as defined by ATP III/NCEP [diabetes, PAD, etc.])

Not applicable

Risk score utilized

Calculated Risk score

Text

Optional

Framingham22

ATP III

ASCVD

Pooled cohort

Other

Pretest probability of CAD—patients with chest pain

Diamond and Forrester calculation23

Text

Optional

Low (<10%)

Intermediate (10%–90%)

High (>90%)

Known CAD

Not applicable

Chest pain symptom stability

History of chest pain pattern

Text

Optional

Stable

Worsening

Prior testing

Prior cardiac testing (multi-select)

Text

Recommended

ETT

Perfusion imaging

Stress echo

Catheterization

MRI

CT

Inflammation imaging

Sarcoid imaging

Amyloid imaging

FPRNA

ERNA

PET

Unknown

None

Date of prior testing

Date of prior cardiac testing

Date

Recommended

mm/dd/yyyy

HDL cholesterol

HDL cholesterol level

Numerical

Optional

XX units

LDL cholesterol

HDL cholesterol level

Numerical

Optional

XX units

Total cholesterol

Total cholesterol level

Numerical

Optional

XXX units

Appropriate use criteria

Appropriate use criteria indication

Text

Required

Appropriate (Indication xx)

Maybe appropriate

Seldom appropriate

Appropriate use criteria utilized

Appropriate use criteria utilized

Text

Required

CMS-approved AUC**

Comments

 

Text

Optional

Free text comments

SOB, shortness of breath; CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; CAD, coronary artery disease; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; MI, myocardial infarction; 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 angiography; ERNA, equilibrium radionuclide angiocardiography; PET, positron emission tomography

* CAD definition: Known significant narrowing of the coronary arteries with or without obstruction; treated CAD is also included

** Please see approved CMS website for updated information24; ASNC recommends the 2013 multisocietal multimodality Appropriate Use Criteria for the detection and risk assessment of stable ischemic heart disease.25

The specific purpose for which the test is being performed must be clearly identified. This provides the required documentation for the medical necessity of the study and focuses the report on the question asked by the referring physician. The structured data elements that relate to the indication are in Table 3. The structured reports must contain sufficient information from these areas to ensure correct identification of the patient. The reports must also convey the specific indications for the study and the pertinent portions of the clinical history that allow the caregivers to appropriately place the imaging results in clinical context. This would include the patient’s current symptoms or other indication for which the study is being performed, current medications, cardiac history with pertinent risk factors including risk factoring scoring, and prior testing, and therapeutic procedures.

Appropriate Use Reporting

Greater emphasis including elevating to required status for reporting AUC has been a significant change in this document. In response to rapid and unsustainable growth in utilization of radionuclide MPI, professional medical organizations developed appropriate use criteria (AUC) to guide physicians and payers on the effective use of these procedures.26 Based on symptoms, coronary risk factors, and cardiac history, the AUC classifies testing across a range of clinical scenarios in three categories: appropriate (established value), may be appropriate (uncertain value), and rarely appropriate (no clear value).25 A significant body of literature demonstrated that appropriate MPI use enhances its acumen in risk stratification, reduces radiation risk, and improves its clinical value.27-33 Physicians are faced with multiple, occasionally discordant, AUC from different organizations. For example, there is substantial discordance between the multimodality AUC for the detection and risk assessment of stable ischemic heart disease developed by the American College of Cardiology, ASNC, and several other societies and the Appropriateness Criteria set forth by the American College of Radiology (ACR). ASNC recommends the AUC promulgated by the ACC as they are best validated and have been shown to be more effective in guiding providers toward patients with greater potential for myocardial ischemia than the ACR Appropriateness Criteria.34

For the past decade, AUC has been promoted as a tool to optimize value of imaging studies. Many health organizations have implemented measures to reduce rarely appropriate studies as an academic or quality improvement exercise. Despite the importance of AUC in the clinical domain, documentation of adherence to AUC in the clinical reports has not been required or widely performed. This will change soon. The Centers for Medicare and Medicaid (CMS) is in the process of implementing §218 of Protecting Access to Medicare Act (PAMA) of 2014. As of 2018, this legislation will require the ordering physician to consult AUC using a CMS-approved, computer-based decision support tool (DST) when ordering MPI studies.35 Thus far, CMS has approved many qualified professional organizations that have developed or endorsed applicable AUC; among these, the ACC’s AUC.25 CMS finalized eight “priority clinical areas,” which will be used to benchmark providers according to their use of rarely appropriate imaging procedures. These clinical areas include suspected or diagnosed coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, suspected or diagnosed lung cancer, and neck pain. Suspected or known CAD being a “priority clinical area,” the majority of MPI studies will be used to benchmark the ordering physician.35 Based on PAMA, the imaging specialists will not be paid for their services if they do not have documentation that the ordering physician consulted an AUC DST. After collecting two years of data in the aforementioned eight priority clinical areas, referring physicians who are considered “outliers” in terms of their utilization of rarely appropriate MPI will be subjected to prior authorization when ordering MPI studies. As a result, there will be a massive shift wherein the burden of reducing inappropriate use will move largely from payers to providers.36 Imaging specialists, practicing physicians, and health organizations need to adapt to meet this requirement. Nuclear cardiologist need to find practical ways to obtain and document AUC determination, as discerned by a CMS-approved DST used by the ordering physician.

Study Description

The Study Description should be the next section of the structured report. This section should include all the parameters used in acquiring the study. It must include a description of the stress test performed, including the type of stress test (i.e., exercise or pharmacologic). For stress tests, it is necessary to include the type of protocol, duration of exercise, and its adequacy as determined by exercise time, peak heart rate, percent maximal predicted heart rate (MPHR), pressure rate product (PRP), and estimated metabolic equivalents (METS). For pharmacologic stress tests, the pharmacologic agent used, the dose received, including the infusion rate and duration, hemodynamic response to the dose, and use of adjunctive exercise must be documented. If pharmacologic stress is performed after attempted exercise, exercise parameters should be reported in addition to pharmacologic parameters. The time of administration of radioactivity is also required for either modality. The specific data elements for this section as well as their responses are found in Table 4.
Table 4

Stress testing data

Variable

Description

Datatype

Priority

Response

Test type

Type of test

Text

Required

Rest

Exercise

Pharmacologic

Pharmacologic conversion with prior attempt at exercise

Pharmacologic with fixed low-level exercise

Other

Pharmacologic stress agent

Pharmacologic stress agent

Text

Required

Adenosine

Atropine

Dipyridamole

Dobutamine

Dobutamine and Atropine

Regadenoson

Adenosine Triphosphate*

Other

Indication for pharmacologic stress

Reason exercise only is not appropriate

Text

Required

LBBB or pacemaker

PET

Inability to exercise adequately

Unable to exercise

Other

Pharmacologic stress dose

Pharmacologic stress dose

Text

Required

Units

Pharmacologic stress time

Time to deliver pharmacologic stress dose

Numerical

Required

XX:XX min:sec

Pharmacologic stress exercise

Adjunctive low-level exercise use

Text

Required

Yes

No

Estimated ability to exercise

Pretest estimate of ability to exercise based on daily activities

Test

Recommended

Less than 4 METS

Greater than or equal to 4 METS

Exercise protocol

Exercise protocol used

Text

Required

Arm ergometry

Bicycle ergometer

Bruce

Fixed low level for use in combination with vasodilating agents

Modified Bruce

Modified Naughton

Naughton

Ramp

Other

Resting HR

Resting HR

Numerical

Required

Beats/minute

Resting BP

Resting BP

Numerical

Required

mm Hg

Stress HR

Maximum HR achieved

Numerical

Required

Beats/minute

HR Response to exercise

HR response to exercise

Text

Recommended

Normal

Blunted

Accentuated

HR Response to vasodilator stress

% change in HR from baseline to peak (Max HR − Baseline HR)/Baseline HR

Numerical

Optional

Normal

Blunted

Heart rate recovery

Heart rate recovery at 1 min

Text

Optional

Normal (>12 bpm)

Abnormal (<12 bpm)

% MPHR

% of MPHR

Numerical

Required

%

Stress BP

Peak BP achieved during test

Numerical

Required

mm Hg

BP response

BP response to exercise

Text

Recommended

Blunted

Hypertensive

Hypotensive

Normal

Pressure rate product

SBP × HR

Numerical

Optional

Adequate (≥25,000)

Inadequate (<25,000)

Exercise duration

Time on treadmill/bicycle

Numerical

Required

Minutes (0.0 format)

Functional capacity

Exercise functional capacity

Text

Recommended

Average

Below average

Above average

METS

Peak estimated METS level

Numerical

Recommended

METS

Anginal stress symptoms

Chest pain symptoms during stress

Text

Required

Typical angina

Atypical angina

Non-anginal chest pain

Anginal equivalent

No chest pain

Duration of symptoms

Duration of anginal stress symptoms

Numerical

Required if anginal stress symptom is present

XX:XX min:sec

Severity of anginal symptoms

Severity of anginal symptoms

Numerical

Required if anginal stress symptom is present

Numerical value on 1–10 scale (1, mild; 10, severe)

Other stress symptoms

Other symptoms during stress

Text

Recommended

Claudication

Dizziness

Dyspnea/SOB

Fatigue

Flushing

Nausea

Syncope

Reason for termination

Reason for termination

Text

Required

Achievement of target HR

Arrhythmia

Chest pain

Claudication

CNS symptoms

Conduction abnormalities

Drop in systolic blood pressure

Dyspnea

ECG changes

End of protocol

Fatigue

Hypertension

Hypotension

Increasing chest pain

Leg pain

Moderate to severe angina

Mortality

Non-CNS symptoms

Patient request

Procedure-related complication

Reached target HR

Signs of poor perfusion

Technical problems

Other

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

* Used internationally

The electrocardiographic (ECG) data pertinent to the test should be reported next. This would include the presence of any baseline ECG abnormalities that might preclude a conclusive interpretation of the ECG stress portion of the test (Table 5).
Table 5

Resting ECG data

Variable

Description

Datatype

Priority

Response

Rest rhythm

Resting ECG rhythm

Text

Required

Sinus rhythm

Sinus bradycardia

Sinus tachycardia

Junctional rhythm

Ectopic atrial rhythm

Atrial fibrillation

Atrial Flutter

Atrial paced

Ventricular paced

AV sequential paced

Other

Resting conduction

Resting AV conduction

Text

Required

Normal

IVCD

LBBB

RBBB

Incomplete RBBB

Incomplete LBBB

RBBB + LAFB

RBBB + LPFB

First-degree AV block

Second-degree AV block

Third-degree AV block

Pre-excitation

Other

Resting arrhythmias

Resting ECG arrhythmias

Text

Required

None

APC

VPC

Non-sustained ventricular tachycardia

Repolarization

Resting ECG repolarization

Text

Required

Normal

Early repolarization

Non-specific ST-T abnormality

ST depression

ST elevation

Secondary ST-T abnormality

ECG interpretable

Resting ECG able to be interpreted for ischemia*

Text

Recommended

Interpretable for ischemia

Not interpretable for ischemia

HR, heart rate; BP, blood pressure; ECG, Electrocardiographic; SVT, supraventricular tachycardia; AV, atrioventricular; IV, intraventricular; IVCD, intraventricular conduction delay; LBBB, left bundle branch block; RBBB, right bundle branch block; LAFB, left anterior fascicular block; LPFB, left posterior fascicular block; APC, atrial premature contraction; VPC, ventricular premature contraction

* The absence of resting ST-segment changes, T wave changes, left bundle branch block (LBBB), pre-excitation (Wolf–Parkinson–White Syndrome), left ventricular hypertrophy, digoxin use, or paced rhythm, any of which would preclude the accurate interpretation of ischemic changes on the ECG

The stress ECG interpretation must evaluate the parameters defined in Table 6, commenting on any changes from baseline with regards to either the ST segments or onset of arrhythmias. Comparison to prior tests and inclusion of parameters that allow calculation of validated risk scores (e.g., the Duke treadmill score)37 are recommended. Ideally, Stress ECG data would be presented in a tabular format, with documentation of many of the following variables at each stage of stress and recovery.
Table 6

Stress ECG data

Variable

Description

Datatype

Priority

Response

Stress rhythm

Stress ECG rhythm

Text

Required

Sinus rhythm

Sinus bradycardia

Sinus tachycardia

Junctional rhythm

SVT

Ectopic atrial rhythm

Atrial fibrillation

Atrial flutter

Atrial paced

Ventricular paced

AV sequential paced

Other

Stress conduction

Stress ECG AV conduction

Text

Recommended

Normal

IVCD

LBBB

RBBB

Incomplete RBBB

Incomplete LBBB

Bifascicular block

RBBB + LAFB

RBBB + LPFB

First-degree AV block

Second-degree AV block

Third-degree AV block

Stress arrhythmias

Stress-induced ECG arrhythmias

Text

Required

None

APC

VPC

Atrial fibrillation

SVT

Non-sustained ventricular tachycardia

Ventricular tachycardia

Ventricular fibrillation

Stress repolarization

Resting repolarization abnormalities

Text

Required

Normal

Early repolarization

Non-specific ST-T changes

ST depression

ST elevation

Secondary ST-T changes

ST-segment change in each stage

ST-segment change in each stage

Text

Required

Normal

Non-diagnostic low heart rate

Non-diagnostic resting ST abnormalities

Non-diagnostic V-pacing or LBBB

ST-segment depression amount in each stage

Millimeters of ST-segment change

Numerical

Required if ST-segment change is not normal

mm

Maximum ST-segment change

Maximum millimeters of ST-segment change

Numerical

Required if ST-segment change is not normal

mm

ST-segment configuration

Configuration of ST-segment change

Text

Required if ST-segment change is not normal

Horizontal

Upsloping

Downsloping

Elevation

ST-segment location

Location of ST-segment change

Text

Required if ST-segment change is not normal

Anterior

Inferior

Lateral

Septal

Apical

Number of leads with ST-segment change

Number of leads with ST-segment change

Numerical

Required if ST-segment change is not normal

XX

Timing of ST-segment depression

Time when ST-segment depression occurs

Text

Required if ST-segment change is not normal

Stress only (minute or stage of exercise)

Stress and recovery

Recovery only

Timing of resolution of ST changes

Time when ST-segment depression returns to normal

Text

Recommended

Stress or recovery

Presence of Resolution of ST segments within 1 min

If ST segments resolve within 1 min

Text

Recommended

Rapid resolution of ST segments (decreases the specificity of the test)

ETT compared to prior-exercise tolerance

Comparison to prior ETT (METS)

Text

Recommended

Same

Lower

Higher

ETT compared to prior-ST segment

Comparison of ST segment to prior test

Text

Recommended

No change

New ischemia

Resolution of ischemia

Ischemia at higher workload

Ischemia at lower workload

Duke treadmill score

Duke score

Numerical

Recommended

XXX

Duke treadmill score risk category

Duke prognosis

Text

Recommended (derived)

Low

Moderate

High

Heart rate recovery

Heart rate recovery

Text

Recommended (derived)

Normal

Abnormal

ECG, electrocardiographic; SVT, supraventricular tachycardia; AV, atrioventricular; IV, intraventricular; IVCD, intraventricular conduction delay; LBBB, left bundle branch block; RBBB, right bundle branch block; LAFB, left anterior fascicular block; LPFB, left posterior fascicular block; APC, atrial premature contraction; VPC, ventricular premature contraction; ETT, exercise tolerance test; METS, metabolic equivalents

The structured report format continues with variables that define the imaging process including the protocol utilized, the patient position, and radiopharmaceutical doses administered to the patient. It also includes their time of administration and whether attenuation correction or other modalities were used. These data elements are presented in detail in Tables 7, 8, 9, and 10.
Table 7

Imaging parameters

Variable

Description

Datatype

Priority

Response

Perfusion imaging protocol

Describes protocol used to acquire perfusion images

Text

Required for perfusion

Rest

Rest/delayed rest

Rest/stress 1-day

Rest/stress 2-day

Stress only

Stress/rest 1-day

Stress/rest 2-day

Stress/rest/delayed rest

ERNA modified in vivo/in vitro labeling

ERNA in vitro labeling

FPRNA

Other

Metabolic imaging Protocol

Describes protocol used to acquire metabolic images

Text

Required for metabolic imaging

Metabolic viability

Metabolic inflammation

Study acquisition

Mode study acquired in

Text

Required for ERNA and FPRNA

Gated SPECT

Frame mode acquisition

Imaging position

Describes patient positioning

Text

Recommended

Supine

Prone

Upright

Stress radiopharmaceutical

Stress imaging agent used

Text

Required

N-13 Ammonia

O-15 Water

Rb-82

Tc-99m Tetrofosmin

Tc-99m Sestamibi

Thallium-201

Stress dose

Dose of radioactivity

Numerical

Required

Numerical value XX.X

Stress date

Date of stress study

Numerical

Required

XX/XX/XXXX

Stress injection time

Time of stress injection

Numerical

Recommended

Month/day/year XX:XX:XX (hours)

Stress imaging time

Time of stress imaging

Numerical

Required

Month/day/year XX:XX:XX (hours)

Exercise time after injection

Exercise time after injection

Numerical

Optional

XX:XX min:sec

Rest radiopharmaceutical

Rest imaging agent used

Text

Required

I-123

N13-Ammonia

O-15 Water

Rb-82

Tc-99m PYP

Tc-99m Tetrofosmin

Tc-99m Sestamibi

Thallium-201

Rest dose

Dose of radioactivity

Numerical

Required

Numerical value XX.X

Rest date

Date of rest study

Numerical

Required

mm/dd/yyyy

Rest injection time

Time of rest injection

Numerical

Recommended

Month/day/year XX:XX:XX (hours)

Rest imaging time

Time of rest imaging

Numerical

Required

Month/day/year XX:XX:XX (hours)

Viability/metabolic/inflammation radiopharmaceutical

Viability/metabolic/inflammation imaging agent used

Text

Required

Tl-201

F-18 FDG

Viability dose

Dose of radioactivity

Numerical

Required

Numerical value XX.X

Viability date

Date of viability study

Numerical

Required

mm/dd/yyyy

Viability injection time

Time of viability Injection

Numerical

Recommended

Month/day/year XX:XX:XX (hours)

Viability imaging time

Time of viability imaging

Numerical

Required

Month/day/year XX:XX:XX (hours)

Rest/delayed imaging time

Time difference between rest and delayed images

Text

Required

Month/day/year XX:XX:XX (hours)

Fasting state

Fasting state of the patient

Text

Required (PET only)

Glucose-loaded

Fasting

Carb restricted/Fasting

Camera

Vendor and name of camera

Text

Recommended

Digirad

GE

Phillips

Mediso

Siemens

Spectrum dynamics

Toshiba

Other

Quantitative software

Vendor/name of processing software used

Text

Recommended

Cedars-Sinai

Digisonics

GE

Generic

INVIA

Philips

Positron

Siemens

Syntermed

Other

Attenuation correction

Use of attenuation correction

Text

Required

Yes—stress only

Yes—stress/rest

No

Attenuation correction type

Type of attenuation correction

Text

Required if attenuation correction type is yes

CT scan

Transmission

Prone imaging—stress only

Prone imaging—stress/rest

Other (if this value is selected, complete the Other text field)

Attenuation correction type other

Other type of attenuation correction

Text

Required if attenuation correction type other is selected

Variable

Motion correction

Motion correction software used

Text

Optional

Yes

No

Resolution recovery

Resolution recovery software used

Text

Optional

Yes

No

Half-time imaging

Half-time imaging used

Text

Optional

Yes

No

Half-dose imaging

Half-dose imaging used

Text

Optional

Yes

No

CT, Computed tomography; FDG, fluorodeoxyglucose; ERNA, equilibrium radionuclide angiocardiography; FPRNA, first-pass radionuclide angiography; SPECT, single-photon emission computed tomography; DTPA, diethylene triamine pentaacetic acid; HDP, hydroxymethylene diphosphonate; PET, positron emission tomography

Table 8

Additional imaging parameters specific to viability studies

Variable

Description

Datatype

Priority

Response

Viability imaging wait time

Time from injection to start of image acquisition

Text

Required

XX.X minutes

Imaging parameters specific to F-18 FDG PET viability study

 Fasting state

Patient was fasting

Text

Required

Yes

No

 Fasting time

Time patient fasted prior to viability study

Numerical

Required

Month/day/year XX:XX:XX (hours)

 Glucose protocol

Type of patient preparation used for viability assessment

Text

Recommended

Oral glucose load

Euglycemic- hyperinsulinemic clamp

 Blood glucose level

Blood glucose level of patient at time of FDG injection

Numerical

Recommended

XX units

Imaging parameters specific to Tl-201 SPECT viability study

 Redistribution imaging time

Time from injection to start of image acquisition

Text

Required

XX:XX hours:minutes

 Additional redistribution imaging time (if applicable)

Time from initial Tl-201 injection to start of additional image acquisition

Text

Required (if additional 18- to 24-hour redistribution images are obtained)

XX:XX hours:minutes

 Reinjection (if additional dose of Thallium is given)

Dose of radioactivity

Numerical

Required if additional dose is given

XX.X units

 Nitrate-enhanced protocol used

Use of nitrates to enhance viability assessment

Text

Recommended

Yes

No

FDG, fluorodeoxyglucose; PET, positron emission tomography

Table 9

Imaging parameters specific for inflammation/infection

Variable

Description

Datatype

Priority

Response

Inflammation/infection imaging wait time

Time from injection to start of image acquisition

Text

Required

XX minutes (0.0 format)

Fasting state

Fasting state of the patient

Text

Required

Yes

No

Fasting time

Time patient fasted prior to inflammation/infection study

Numerical

Required

XX:XX hours

Diet protocol

Use of high fat/low carbohydrate diet

Text

Recommended

Yes

No

Unfractionated heparin

Use of unfractionated heparin prior to inflammation/infection scan

Text

Recommended

Yes

No

Unfractionated heparin dose(s)

Dose(s) of unfractionated heparin used prior to inflammation/infection scan

Numerical

Recommended

XX IU/kg

XX doses

Timing of unfractionated heparin dose

Administration of dose relative to injection of F-18 FDG in infection/inflammation scan

Numerical

Recommended

XX.X minutes prior to injection of F-18 FDG

Blood glucose level

Blood glucose level of patient at time of FDG injection

Numerical

Recommended

XX units

IU, international unit; kg, kilogram; FDG, fluorodeoxyglucose

Table 10

Imaging parameters for Tc-99m PYP

Variable

Description

Datatype

Priority

Response

Rest radiopharmaceutical

Rest imaging agent used

Numerical

Required

XX.X units

Time between injection and acquisition

Time between injection of Tc-99m PYP and imaging

Text

Required

XX:XX:XX (hours:minutes:seconds)

Field of view

Field of view for image acquisition

Text

Required

Cardiac or chest

Whole body

Imaging protocol

Describes protocol used to acquire images

Text

Required

Rest Tc-99m PYP

Study acquisition

Scan technique

Text

Required

Planar

Gated SPECT

Both planar and gated SPECT

Imaging position

Describes patient positioning

Text

Required

Supine

Imaging views

Angulation of camera for image acquisition

Text

Required

Anterior

Lateral

Left anterior oblique

Image duration

Count-based image duration

Numerical

Recommended

XX counts

PYP, pyrophosphate; SPECT, single-photon emission computed tomography

Following the section on imaging parameters, the left ventricular (LV) perfusion results should be provided. The results will differ slightly for SPECT vs PET MPI. Every qualitative assessment of LV perfusion should include a summary that provides an overall statement of LV perfusion abnormality. This should be followed by the size, location, severity, and degree of reversibility of any perfusion defects as shown in Table 11. Perfusion defect location should be described according to the standardized 17-segment model (Appendix 6). This pattern can be repeated for multiple perfusion abnormalities. Inclusion of a bulls-eye polar plot showing the location and degree of perfusion defects can aid in visualization. The associated segmental function of myocardium with a perfusion defect can inform the clinical interpretation. A clinical interpretation of each perfusion defect provided in this portion of the report can help increase clarity (ischemia, infarction, peri-infarct ischemia). Any uncertainty can be reported here. For instance, probable ischemia (vs artifact) can be selected when perfusion is probably abnormal or probable artifact can be chosen if perfusion is categorized as probably normal. Classification of the perfusion defect as visual only, quantitative only, or visual and quantitative is optional but provides additional information on the degree of evidence to support the conclusions made. The presence or absence of transient ischemic dilation (TID) is a required element and can also be classified as visual, quantitative, or both. Reporting of the stress and rest perfusion cavity sizes and ratio of these two parameters (the TID ratio) are optional. The presence of normal LV tracer uptake and myocardial wall thickness vs increased values in the setting of LV hypertrophy should be documented. Finally, increased tracer uptake in the right ventricle and the lungs at stress and rest can be reported.
Table 11

Qualitative LV perfusion assessment (SPECT and PET)

Variable

Description

Datatype

Priority

Response

LV perfusion summary

Summary of left ventricular perfusion

Text

Required

Normal

Probably normal

Probably abnormal

Abnormal

Equivocal

Perfusion Defect size

Size of perfusion defect

Text

Required

Small (1–2 segments)

Medium (3–4 segments)

Large (≥5 segments)

Perfusion defect location

Location of perfusion defect

Text

Required

Basal anterior (1)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

Perfusion defect severity

Severity of perfusion defect

Text

Required

Mild (10%–<25% reduction from baseline)

Moderate (25%–<50% reduction from baseline)

Severe (≥50% reduction from baseline)

Absent tracer uptake (background radiation levels)

Reversibility degree

Degree of reversibility

Text

Required

Reversible

Fixed (no reversibility)

Mildly reversible

Moderately reversible

Predominantly reversible

Predominantly fixed

Segmental function

Classification of the function of the myocardial region with abnormal perfusion

Text

Required if abnormal

Normal

Abnormal

Perfusion defect clinical interpretation

Clinical interpretation of the perfusion defect

Text

Recommended

Ischemia

Infarction

Ischemia and infarction

Peri-infarct ischemia

Probable ischemia

Probable infarction

Probable artifact

Uninterpretable

Perfusion defect classification

Classification of the perfusion defect as present visually, quantitatively, or both

Text

Optional

Visual only

Quantitative only

Visual and quantitative

Bulls-eye polar plot

Bulls-eye polar plot of perfusion defect location and severity

Figure

Optional

Bulls-eye polar plot of the 17 segments with each color coded by perfusion defect severity

TID

Qualitative assessment of transient ischemic dilation

Text

Required

Present

Absent

Unable to assess (for Stress-only imaging)

TID classification

Classification of TID as present visually, quantitatively, or both

Text

Recommended

Visual only

Quantitative only

Visual and quantitative

Stress perfusion cavity size

Non-gated perfusion cavity size at stress

Numerical

Optional

XXX mL

Rest perfusion cavity size

Non-gated perfusion cavity size at rest

Numerical

Optional

XXX mL

TID ratio

Ratio of stress to rest perfusion cavity sizes

Numerical

Optional

XX:XX ratio

LV myocardial wall thickness

Presence of increased wall thickness consistent with hypertrophy.

Text

Required

Increased

Normal

Stress RV myocardial uptake

RV tracer uptake at stress

Text

Optional

Normal

Increased

Rest RV myocardial uptake

RV tracer uptake at rest

Text

Optional

Normal

Increased

Lung uptake, stress

Stress lung uptake

Text

Optional

Yes

No

Lung uptake, rest

Tracer uptake in the lungs at rest

Text

Optional

Yes

No

The information in this table may be repeated as required to describe multiple perfusion defects

TID, transient ischemic dilation; LV, left ventricular; RV, right ventricular

Quantitative image processing for LV perfusion is recommended, with suggested data elements outlined in Table 12. Each segmental score should be adjusted for attenuation prior to calculation. No segment should have a negative score. The derived extents of perfusion and ischemia require division of the respective SSS, SRS, and SDS by 68, the maximal perfusion score of 4 across all 17 segments.
Table 12

Quantitative LV perfusion assessment (SPECT and PET)

Variable

Description

Datatype

Priority

Response

Summed stress score (SSS)

Extent and severity of LV perfusion defects at stress across the 17 segments.

Numerical

Recommended

XX

Summed rest score (SRS)

Extent and severity of LV perfusion defects at rest across the 17 segments.

Numerical

Recommended

XX

Summed difference score (SDS)

SSS–SRS. Extent and severity of reversible perfusion defects across the 17 segments.

Numerical

Recommended (derived)

XX

Stress perfusion extent

SSS/68% myocardium with perfusion defects at stress.

Numerical

Recommended (derived)

XX%

Rest perfusion extent

SRS/68% myocardium with perfusion defects at stress.

Numerical

Recommended (derived)

XX%

Stress ischemia extent (% LV ischemia)

SDS/68% myocardium with reversible perfusion defects at stress.

Numerical

Recommended (derived)

XX%

SSS, summed stress score; SRS, summed rest score; SDS, summed difference score

Stress and/or rest-gated imaging should be performed when technically feasible. LV global and segmental function and volumes should be reported as detailed in Tables 13 and 14. The timing of stress function assessment (during stress [i.e., first-pass], post-stress, rest) is recommended. The following values can be repeated for each phase assessed (stress and rest). An overall assessment of global LV function is required, and the calculated left ventricular ejection fraction (LVEF) should be provided. Segmental functional abnormalities can be described both by regional thickening and wall motion. Severity should be described by location according to the 17-segment model.17 Numerical documentation of LV volumes and/or volume indices and subjective assessment of the LV cavity sizes at both end-diastole and end-systole are optional. The information in these tables may be repeated as required to describe multiple perfusion defects.
Table 13

LV gated functional and volume assessment at stress

Variable

Description

Datatype

Priority

Response

Timing of function

Timing of function assessment

Text

Recommended

During exercise (i.e., first-pass)

Post-stress

Stress global LV function

Subjective assessment of global LV function

Text

Required

Normal (>55%–<70%)

Low normal (50%–55%)

Mildly reduced (45%–<50%)

Moderately reduced (35%–<45%)

Severely reduced (<35%)

Hyperdynamic (≥70%)14

Stress LVEF

Calculated quantitative LVEF

Numerical

Required

XX%

Stress regional wall thickening

Subjective regional wall thickening (WT)

Text

Recommended

Normal

Mildly decreased WT

Moderately decreased WT

Severely decreased WT

Hyperdynamic WT

Stress regional wall-thickening location

Subjective regional wall-thickening location

Text

Recommended

Basal anterior (1)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

Stress regional wall motion

Subjective regional wall-motion assessment

Text

Recommended

Normal

Mild hypokinesis

Moderate hypokinesis

Severe hypokinesis

Akinesis

Dyskinesis

Stress regional wall-motion location

Subjective regional wall-motion location

Text

Recommended

Basal anterior (1)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

Stress LV end-diastolic volume (EDV)

LVEDV

Numerical

Optional

XXX mL

Stress LV end-diastolic volume index (EDVI)

LVEDV normalized to body surface area

Numerical

Optional

XXX mL/m2

Stress LV end-diastolic cavity size

Subjective assessment of LV end-diastolic cavity size

Text

Optional

Normal

Mildly enlarged

Moderately enlarged

Severely enlarged

Stress LV end-systolic volume (ESV)

LVESV

Numerical

Optional

XXX mL

Stress LV end-systolic volume index (ESVI)

LVESV normalized to body surface area

Numerical

Optional

XXX mL/m2

Stress LV end-systolic cavity size

Subjective assessment of LV end-systolic cavity size

Text

Optional

Normal

Mildly enlarged

Moderately enlarged

Severely enlarged

Stress LV diastolic function—qualitative

Visual assessment of time-activity curve

Text

Optional

Normal

Abnormal

Stress LV diastolic function—quantitative

LV peak filling rate

Numerical

Optional

X.XX EDV/second

The information in this table may be repeated as required to describe multiple segmental functional abnormalities

LV, left ventricular; EF, ejection fraction; EDV, end-diastolic volume; EDVI, end-diastolic volume index; ESV, end-systolic volume; ESVI, end-systolic volume index; WT, wall thickening

Table 14

LV gated functional and volume assessment at rest

Variable

Description

Datatype

Priority

Response

Resting global LV function

Qualitative assessment of global LV function at rest

Text

Required

Normal (>55%–<70%)

Low normal (50%–55%)

Mildly reduced (45%–<50%)

Moderately reduced (35%–<45%)

Severely reduced (<35%)

Hyperdynamic (≥70%)14

Resting LVEF

Calculated quantitative LVEF

Numerical

Required

XX%

Resting regional wall thickening

Subjective regional wall thickening

Text

Recommended

Normal

Mildly decreased WT

Moderately decreased WT

Severely decreased WT

Hyperdynamic WT

Resting regional wall-thickening location

Subjective regional wall-thickening location

Text

Recommended

Basal anterior (1)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

Resting regional wall motion

Subjective regional wall-motion assessment

Text

Recommended

Normal

Mild hypokinesis

Moderate hypokinesis

Severe hypokinesis

Akinesis

Dyskinesis

Resting regional wall-motion location

Subjective regional wall-motion location

Text

Recommended

Basal anterior (1)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

Resting LV end-diastolic volume (EDV)

LVEDV

Numerical

Optional

XXX mL

Resting LV end-diastolic volume index (EDVI)

LVEDV normalized to body surface area

Numerical

Optional

XXX mL/m2

Resting LV end-diastolic cavity size

Subjective assessment of LV end-diastolic cavity size

Text

Optional

Normal

Mildly enlarged

Moderately enlarged

Severely enlarged

Resting LV end-systolic volume (ESV)

LVESV

Numerical

Optional

XXX mL

Resting LV end-systolic volume index (ESVI)

LVESV normalized to body surface area

Numerical

Optional

XXX mL/m2

Resting LV end-systolic cavity size

Subjective assessment of LV end-systolic cavity size

Text

Optional

Normal

Mildly enlarged

Moderately enlarged

Severely enlarged

Resting LV diastolic function—qualitative

Visual assessment of time-activity curve

Text

Optional

Normal

Abnormal

Resting LV diastolic function—quantitative

LV peak filling rate

Numerical

Optional

X.XX EDV/second

The information in this table may be repeated as required to describe multiple segmental functional abnormalities

LV, left ventricular; EF, ejection fraction; EDV, end-diastolic volume; EDVI, end-diastolic volume index; ESV, end-systolic volume; ESVI, end-systolic volume index; WT, wall thickening

LV perfusion and function assessment by PET has additional parameters not typically assessed in SPECT studies that can be reported as shown in Table 15. Stress and rest myocardial blood flow (MBF) can be quantitated during PET MPI and can provide additional information on LV perfusion. Values are typically provided for stress and rest globally and by coronary perfusion territory (left anterior descending [LAD], left circumflex [LCX], right coronary artery [RCA]). The ratio of stress to rest flow is defined as the myocardial flow reserve. Stress MBF and MFR can be classified as preserved (>2 mL/min/g), mildly reduced (1.5-2 mL/min/g), or severely reduced (<1.5 mL/min/g).20 Thresholds for MBF and MFR can vary by protocol and lab. The calculation of a true stress LVEF during vasodilator stress has led to calculation of LVEF reserve, the difference between stress and rest LVEFs that has diagnostic and prognostic significance. An LVEF reserve <0%, indicating a drop in LVEF with stress, has diagnostic and prognostic significance and can be optionally reported.38
Table 15

Additional PET-specific LV perfusion and function parameters

Variable

Description

Datatype

Priority

Response

Stress myocardial blood flow

Stress myocardial blood flow in mL/min/g

Numerical

Optional

Global: X.XX mL/min/g

LAD Territory: X.XX mL/min/g

LCX Territory: X.XX mL/min/g

RCA Territory: X.XX mL/min/g

Stress myocardial blood flow conclusion

Subjective assessment of stress myocardial blood flow

Text

Optional

Preserved (>2 mL/min/g)

Mildly reduced (1.5–2 mL/min/g)

Severely reduced (<1.5 mL/min/g)

Rest myocardial blood flow

Rest myocardial blood flow in mL/min/g

Numerical

Optional

Global: X.XX mL/min/g

LAD Territory: X.XX mL/min/g

LCX Territory: X.XX mL/min/g

RCA Territory: X.XX mL/min/g

Rest myocardial blood flow conclusion

Subjective assessment of absolute rest myocardial blood flow

Text

Optional

Preserved (>2 mL/min/g)

Mildly reduced (1.5–2 mL/min/g)

Severely reduced (<1.5 mL/min/g)

Myocardial flow reserve (MFR)

Ratio of stress and rest myocardial blood flows

Numerical

Optional (derived)

Global: X.XX

LAD Territory: X.XX

LCX Territory: X.XX

RCA Territory: X.XX

MFR conclusion

Subjective assessment of myocardial flow reserve

Text

Optional

Preserved (>2)

Mildly reduced (1.5–2.0)

Severely reduced (<1.5)

LVEF reserve

Difference between the stress and rest LVEF

Numerical

Optional (derived)

XX%

LVEF reserve conclusion

Subjective assessment of LVEF reserve

Text

Optional

Normal (≥0%)

Abnormal (<0%)

LAD, left anterior descending; LCX, left circumflex; RCA, right coronary artery; MFR, myocardial flow reserve; LVEF, left ventricular ejection fraction

SPECT and PET MPI also allow interpretation of the perfusion, size, and global and segmental function of the right ventricle (RV). Data elements for this assessment are provided in Table 16. These parameters are not typically reported unless abnormal or in the presence of specific indications for their assessment.
Table 16

Right Ventricular Perfusion and Function Parameters

Variable

Description

Datatype

Priority

Response

RV perfusion

Subjective assessment of the perfusion of the RV

Text

Optional

Normal

Abnormal

Global RV function

Subjective assessment of global RV function

Text

Optional

Normal

Mildly reduced

Moderately reduced

Severely reduced

RVEF

Calculated quantitative RVEF

Numerical

Optional

XX%

RV end-diastolic volume (EDV)

RVEDV

Numerical

Optional

XXX mL

RV end-diastolic cavity size

Subjective assessment of RV end-diastolic cavity size

Text

Optional

Normal

Mildly enlarged

Moderately enlarged

Severely enlarged

RV end-systolic volume (ESV)

RVESV

Numerical

Optional

XXX mL

RV end-systolic cavity size

Subjective assessment of RV end-systolic cavity size

Text

Optional

Normal

Mildly enlarged

Moderately enlarged

Severely enlarged

RV regional wall motion

Subjective assessment of regional wall motion

Text

Optional

Normal

Abnormal

RV regional wall motion

Subjective comparison of RV regional wall motion with perfusion

Text

Optional

Consistent with perfusion

Inconsistent with perfusion

RV, right ventricular; FPRNA, first-pass radionuclide angiography; ERNA, equilibrium radionuclide angiocardiography; EF, ejection fraction, LV, left ventricle; EDV, end-diastolic volume; ESV, end-systolic volume

There are several miscellaneous factors that should be present in the report and will be detailed in Table 17. Comment on the overall study quality can assist in study interpretation and serve as a quality reporting mechanism for the nuclear laboratory. Appreciated artifacts seen on the primary MPI images and CT attenuation correction images should be documented. Increased lung uptake can be commented on, particularly in the setting of Thallium administration. Finally, any incidental findings should be documented including from any associated CT attenuation correction images.
Table 17

Miscellaneous data

Variable

Description

Datatype

Priority

Response

Overall study quality

Overall quality of the study

Text

Required

Excellent

Good

Poor

Uninterpretable

Other

Study quality/artifacts

Specific problems

Text

Recommended

Breast/chest attenuation

Inferior wall/Diaphragmatic attenuation

Motion artifact

Insertion point artifact

LBBB artifact

Subdiaphragmatic activity

Misregistration artifact

Extravasated dose

CT for attenuation correction motion artifact

CT for attenuation correction metal artifact

GI activity

Other (free text)

Extracardiac activity

Describe extracardiac activity

Text

Recommended

Normal

Increased lung uptake

Subdiaphragmatic uptake

Other (free text)

Incidental Findings

Describe any incidental findings

Text

Optional

Free text

CT, computed tomography; GI, gastrointestinal

FPRNA and ERNA

FPRNA and ERNA utilize a number of variables included in other tables, such as those describing LV and RV function at rest and with exercise. Some variables, however, are not covered adequately and are not assignable to other existing tables. Table 18 describes the variables that are recommended for FPRNA and ERNA at rest or with exercise. The majority of the variables in Table 18 are optional, with the required elements noted at the top.
Table 18

FPRNA/ERNA (rest and exercise)

Variable

Description

Datatype

Priority

Response

Rest global LV function

Subjective LV function

Text

Required (at rest and if with exercise)

Normal

Abnormal

Mildly reduced

Moderately reduced

Severely reduced

Rest LVEF

Calculated EF

Numerical

Required (at rest and if with exercise)

XX%

Rest LV volume subjective

Subjective LV volume

Text

Required

Normal

Mildly enlarged

Moderately enlarged

Severely enlarged

LV diastolic function—qualitative

Visual assessment of time-activity curve

Text

Recommended

Normal

Abnormal

LV diastolic function—quantitative

LV peak filling rate

Numerical

Recommended

X.XX EDV/second

Rest regional wall motion

Subjective regional wall motion

Text

Required (at rest and if with exercise)

Normal

Mild hypokinesis

Moderate hypokinesis

Severe hypokinesis

Akinesis

Dyskinesis

Rest regional wall motion location

Subjective regional wall motion

Text

Required (at rest and if with exercise)

Basal anterior (1)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

None

Diffuse

Rest global RV function

Subjective RV function

Text

Required if RV study

Normal

Abnormal

Mildly reduced

Moderately reduced

Severely reduced

Rest RV EF

Calculated EF

Numerical

Required for RV study

XX%

RV volume subjective

Subjective RV volume

Text

Required for RV study

Normal

Mildly enlarged

Moderately enlarged

Severely enlarged

Right atrial size

Visual assessment of RA size

Text

Optional

Normal

Enlarged

Left atrial size

Visual assessment of LA size

Text

Optional

Normal

Enlarged

Aortic size

Size of aorta

Text

Optional

Normal Enlarged

Pulmonary artery Size

Size of pulmonary artery

Text

Optional

Normal

Enlarged

Qualitative change in LV size—change from exercise to rest

Visual assessment of change from rest LV size with exercise

Text

Optional

Same

Larger

Smaller

Quantitative change in LV size—change from exercise to rest

Quantitative assessment of change from rest LV size with exercise

Numerical

Recommended for exercise FPRNA/ERNA

XX mL

Qualitative change in RV size—change from exercise to rest

Visual assessment of change from rest RV size with exercise

Text

Optional

Same

Larger

Smaller

LV regional wall Motion—change from rest

LV regional wall Motion—change from rest

Text

Required for exercise FPRNA/ERNA

List segments in which quantitative score changes by more than 2, where 4 = normal, 3 = mild hypokinesis, 2 = moderate hypokinesis, 1 = severe hypokinesis, 0 = akinetic, -1 = dyskinetic

Basal anterior (1)

Basal anteroseptal (2)

Basal inferior (3)

Basal inferoseptal (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

RV regional wall motion—change from rest

RV regional wall motion—change from rest

Text

Required for exercise FPRNA/ERNA

No change

New wall motion abnormality

RA, right atrium; LA, left atrium; LV, left ventricle; FPRNA; first-pass radionuclide angiography; ERNA, equilibrium radionuclide angiocardiography; RV, right ventricle

Viability Imaging

Viability reporting should detail imaging parameters including patient dietary state; glucose loading or use of the euglycemic-hyperinsulinemic clamp; radiopharmaceutical dose; time of viability imaging; and time delay from injection of radiopharmaceutical to imaging (Tables 7 and 8). Resting left and right ventricular perfusion and function should be described according to parameters listed in Tables 11, 12, 14, and 16.

Assessment of myocardial viability should include visual and quantitative analysis. Metabolism defects, perfusion/metabolism matched defects, and perfusion/metabolism mismatched defects must be described with regards to location, size, and severity.20 The remaining elements in Table 19 are recommended for use in reporting myocardial viability.
Table 19

Viability—qualitative analysis

Variable

Description

Datatype

Priority

Response PET

Response Thallium

Response Technetium

LV size

Cavity size

Text

Recommended

Normal

Normal

Normal

Enlarged

Enlarged

Enlarged

RV size

Cavity size

Text

Recommended

Normal

Normal

Normal

Enlarged

Enlarged

Enlarged

Lung uptake

Lung uptake

Text

Recommended

Yes

Yes

 

No

No

Increased LV uptake

Subjective LV uptake

Text

Optional

Normal

Normal

Normal

Hypertrophied

Hypertrophied

Hypertrophied

Blood pool activity

Blood pool activity

Text

Optional

Normal

  

Increased

Metabolism defect location

Location of metabolism defect

Text

Required

Basal anterior (1)

Basal anterior (1)

Basal anterior (1)

Basal anteroseptal (2)

Basal anteroseptal (2)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferoseptal (3)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferior (4)

Basal inferior (4)

Basal inferolateral (5)

Basal inferolateral (5)

Basal inferolateral (5)

Basal anterolateral (6)

Basal anterolateral (6)

Basal anterolateral (6)

Mid anterior (7)

Mid anterior (7)

Mid anterior (7)

Mid anteroseptal (8)

Mid anteroseptal (8)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferoseptal (9)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferior (10)

Mid inferior (10)

Mid inferolateral (11)

Mid inferolateral (11)

Mid inferolateral (11)

Mid anterolateral (12)

Mid anterolateral (12)

Mid anterolateral (12)

Apical anterior (13)

Apical anterior (13)

Apical anterior (13)

Apical septal (14)

Apical septal (14)

Apical septal (14)

Apical inferior (15)

Apical inferior (15)

Apical inferior (15)

Apical lateral (16)

Apical lateral (16)

Apical lateral (16)

Apex (17)

Apex (17)

Apex (17)

None

None

None

Perfusion/metabolism mismatch

Is there a mismatched perfusion/metabolism defect?

Text

Required

Yes

  

No

Perfusion/metabolism mismatch size

Size of the perfusion/metabolism mismatch

Text

Required

Small

  

Medium

Large

Perfusion/metabolism mismatch location

Location of perfusion/metabolism mismatch

Text

Required

Basal anterior (1)

  

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

None

Perfusion/metabolism match

Is there a matched perfusion/metabolism defect?

Text

Required

Yes

  

No

Perfusion/metabolism match size

Size of the perfusion metabolism match

Text

Required

Small

  

Medium

Large

Perfusion/metabolism match location

Location of perfusion/metabolism match

Text

Required

Basal anterior (1)

  

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

None

Comparison to prior LV viability images

Prior image comparison

Text

Recommended

No change

  

New infarction/scar

Resolution of area of hypoperfusion

LV, left ventricular; RV, right ventricular

The use of quantitative image elements (i.e., number of viable segments and extent of matched and mismatched defects) is also recommended. Table 20 outlines the quantitative data for myocardial viability.
Table 20

Viability—quantitative analysis

Variable

Description

Datatype

Priority

Response PET

Response Thallium

Response Technetium

Number of viable segments

The number of 17-segments that are viable (if PET) or reversible (if Thallium/Technetium)

Numerical

Optional

XX

XX

XX

Metabolism defect extent

Regional metabolism defect extent (% myocardium involved)

Numerical

Optional

XX%

  

Perfusion/metabolism mismatch extent

Extent of perfusion/metabolism mismatch (% of rest perfusion defect)

Text

Optional

XX%

  

Perfusion/metabolism match extent

Extent of perfusion/metabolism match (% of rest perfusion defect)

Text

Optional

XX%

  

Viability extent

Extent of perfusion defect that is viable based on integration of viability radiopharmaceutical uptake, wall thickening and function*

Text

Optional

Entirely >50%

Entirely >50%

Entirely >50%

Minimally (<50%)

Minimally (<50%)

Minimally (<50%)

Viability radiopharmaceutical uptake

Quantitative measure of F-18 FDG radiopharmaceutical uptake in normal and abnormal myocardium (PET only)

Numerical

Optional

XX SUV

  

PET, positron emission tomography; SUV, standard uptake value

* Reported for each perfusion defect

Inflammation and Infection Imaging

Inflammation and infection imaging is based on increased glucose metabolism by activated immune cells.39 In inflammatory conditions (e.g., cardiac sarcoidosis, myocarditis) and infection (e.g., endocarditis, cardiac implantable electrical device [CIED] infections), immune cell activation and infiltration into the myocardium can be visualized by uptake of F-18 FDG, a glucose analog. An important aspect of imaging infection and inflammation is suppression of physiological cardiomyocyte uptake of glucose, so upon injection of F-18 FDG, uptake of the radiopharmaceutical is limited to inflammatory cells.20,40 Reporting should include patient preparation relevant to the suppression of physiological cardiomyocyte glucose uptake as well as abnormal uptake of F-18 FDG (Table 21).
Table 21

Inflammation/infection—qualitative parameters

Variable

Description

Datatype

Priority

Response

LV size

Cavity size

Text

Optional (Recommended in sarcoid)

Normal

Enlarged

RV size

Cavity size

Text

Optional (Recommended in sarcoid)

Normal

Enlarged

Adequacy of suppression of myocardial glucose utilization by normal myocardium

Statement regarding the effectiveness of suppression of basal (normal) glucose uptake by myocardium

Text

Required

Complete suppression

Incomplete suppression

Indeterminate

LV perfusion summary

Summary of left ventricular perfusion

Text

Required

Normal

Probably Normal

Probably abnormal

Abnormal

Equivocal

Myocardial F-18 FDG uptake pattern

Pattern of F-18 FDG uptake by the LV myocardium

Text

Required

Absent

Diffuse

Focal

Focal-on-diffuse

F-18 FDG regional uptake location in the LV myocardium

Location of abnormal F-18 FDG LV myocardial uptake

Text

Required

Basal anterior (1)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

None

Intensity of F-18 FDG uptake

Relative intensity of abnormal F-18 FDG uptake (compared to normal myocardium and/or to blood pool)

Text

Optional

None

Mild uptake

Intense uptake

Extent of F-18 FDG uptake region

Extent of abnormal F-18 FDG uptake in the myocardium

Text

Optional

Small (1–2 segments)

Medium (3–4 segments)

Large (≥5 segments)

None

Co-localization of F-18 FDG uptake regions of abnormal perfusion

Describe if area(s) of abnormal F-18 FDG uptake correspond to regions of abnormal perfusion

Text

Recommended (sarcoidosis scans)

Normal perfusion with absent F-18 FDG uptake

Normal perfusion with increased FDG uptake

Abnormal perfusion with increased FDG uptake

Abnormal perfusion with absent F-18 FDG uptake

Myocardial F-18 FDG uptake-RV

Presence of F-18 FDG uptake in the RV myocardium

Text

Required

Present

Absent

Myocardial F-18 FDG uptake pattern-RV

Comment on focal vs diffuse RV uptake if F-18 FDG uptake is present

Text

Recommended

Focal

Diffuse

Focal-on-diffuse

Site of abnormal F-18 FDG uptake in relation to prosthetic material

Describe if area(s) of abnormal F-18 FDG uptake correspond to site of prosthetic material

Text

Recommended (CIED infection and endocarditis scans)

Skin (superficial)

Subcutaneous tissue

Regions surrounding generator

Leads

Intravascular/Intracardiac

Site of prosthetic valve

Site of aortic graft

Site of other intracardiac prosthetic material

Confirmation of abnormal F-18 FDG uptake on non-attenuation-corrected images

Abnormal F-18 FDG uptake on attenuation-corrected images should be confirmed on non-attenuation-corrected images

Text

Recommended (scans in which there is/are high density metallic devices in the field of view)

Present

Absent

Cardio-synchronous movement of regions of abnormal F-18 FDG uptake

Describe if areas of abnormal F-18 uptake move in a cardio-synchronous manner. Suggesting an intracardiac focus of F-18 FDG uptake

Text

Optional (if gated F-18 FDG images are acquired)

Yes

No

Whole body or chest image interpretation

Describe areas of abnormal F-18 FDG uptake, if whole body F-18 FDG images are acquired

Text

Recommended (can be placed in a separate report if extracardiac findings are interpreted by another physician)

Normal

Abnormal

Comparison to prior inflammation/infection imaging study

Prior image comparison

Text

Recommended

No change

New regions of F-18

FDG uptake (increased or decreased from previous)

New areas of hypoperfusion or resolution of perfusion defects

Comparison to prior rest MPI study and LVEF changes

Yes, especially if area/intensity of scan bigger or smaller

Text

Recommended

No change

New regions of perfusion abnormality

New regions of improved/normalized perfusion

Change in LVEF

Date of prior surgery or CIED implant

Date of insertion of prosthetic material

Date

Recommended (for endocarditis and CIED infection studies)

dd/mm/yyyy

Prior study date

Date of prior study

Date

Recommended

dd/mm/yyyy

LV, left ventricular; RV, right ventricular; FDG, fluorodeoxyglucose; MPI, myocardial perfusion imaging; LVEF, left ventricular ejection fraction; CIED, cardiac implantable electrical device

Assessment of myocardial inflammation includes both visual and quantitative analysis. For sarcoidosis imaging, rest perfusion imaging is required for co-localization of F-18 FDG images with the myocardium and to evaluate for the presence of active inflammation.20,41 Current guidelines do not require myocardial perfusion images for the imaging of cardiovascular device or prosthetic infections.20 Reporting of left ventricular resting perfusion should follow the recommendations set forth in Table 12 of this document. Table 21 lists the qualitative parameters recommended for use in reporting myocardial inflammation and/or infection. The use of quantitative measurements for myocardial uptake of F-18 FDG and for measurement of blood pool (background) activity is summarized in Table 22.
Table 22

Inflammation/infection—quantitative parameters

Variable

Description

Datatype

Priority

Response

Resting LVEF

Calculated LVEF

Numerical

Recommended

XX%

SRS

17-segment SRS

Numerical

Recommended for sarcoid scans

XX

SUVmax background

Maximum SUV for background in blood pool

Numerical

Optional

XX

SUVmax abnormal

Maximum SUV of F-18 FDG uptake in abnormal myocardium or region of CIED/prosthetic material

Numerical

Required

XX

Volume of SUV uptake

Amount of FDG uptake above a pre-specified threshold

Numerical

Recommended

XX mL

LVEF, left ventricular ejection fraction; SRS, summed rest score; SUV, standard uptake value; SUVmax, standard uptake value maximum; CIED, cardiac implantable electrical device

Iodine-123 metaIodobenzylguanidine (I-123 mIBG) Imaging

Reporting metaiodobenzylguanidine (mIBG) imaging should include visual and quantitative analysis. Decreased mIBG uptake and heart-to-mediastinal ratio (HMR) are key components of I-123 mIBG imaging and should be clearly stated in the report.42 Calculation of washout and specific localization of sympathetic activity defects may also be included.43-45 The remaining elements in Table 23 are recommended for use in reporting mIBG imaging.
Table 23

mIBG analysis parameters

Variable

Description

Datatype

Priority

Response

Administration of Lugol’s Iodine or KI prior to mIBG imaging

Whether iodine was administered prior to injection of mIBG

Text

Optional

Yes

No

Imaging Delay

Time from injection of I-123 mIBG to initial planar image and time from early to late mIBG images

Numeric

Required

XX.X minutes

LV size

Cavity size

Text

Recommended

Normal

Enlarged

Rest LVEF

Calculated LVEF

Numerical

Recommended

XX%

LV function

Subjective LV function

Text

Optional (if gated SPECT images are acquired)

Normal

Abnormal

Mildly reduced

Moderated reduced

Severely reduced

Lung Uptake

Lung uptake

Text

Recommended

Yes

No

Overall uptake of mIBG

Global myocardial uptake of mIBG

Text

Required

Normal

Abnormal

Pattern of mIBG uptake

mIBG uptake in the myocardial is homogenous or variable

Text

Recommended

Homogenous uptake

Diffuse uptake abnormalities

Focal uptake abnormalities

Abnormal mIBG uptake

Location of mIBG uptake abnormalities

Text

Recommended (can be derived from SPECT images if performed)

Basal anterior (1)

Basal anteroseptal (2)

Basal inferior (3)

Basal inferoseptal (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

None

Size of mIBG uptake defect

Size of region of abnormal mIBG uptake

Text

Recommended

Small

Medium

Large

Severity of mIBG uptake defect

Intensity of defect in myocardial mIBG uptake

Text

Recommended

Normal

Mild

Moderate

Severe

Heart-to- mediastinal ratio (HMR)

Ratio of uptake in the myocardium divided by a region of interest in the mediastinum

Numeric

Required

XX

Planar images

Reproduction of anterior planar images

Image

Recommended

n/a

Calculation of mIBG washout

Myocardial washout rate of mIBG from early to late images, expressed as a percentage

Numeric

Recommended

XX%

mIBG, metaiodobenzylguanidine, LV, left ventricular; LVEF, left ventricular ejection fraction; SPECT, single-photon emission tomography; HMR, heart-to-mediastinal ratio

Tc-99m Pyrophosphate Imaging for Transthyretin Cardiac Amyloidosis

There is increasing use of Technetium 99m pyrophosphate (Tc-99m PYP) imaging to diagnose cardiac transthyretin amyloidosis (ATTR).46,47 The American Society of Nuclear Cardiology published a Practice Points statement detailing the critical components of Tc-99m PYP imaging and reporting.48 Reports should include semi-quantitative and quantitative analysis of cardiac uptake of Tc-99m PYP in addition to visual scan interpretation (Table 24). The report should include all applicable elements of a nuclear cardiology report as detailed in Tables 1, 2, 3, 7, and 10 of this guideline.
Table 24

Tc-99m PYP analysis parameters

Variable

Description

Datatype

Priority

Response

Myocardial Tc-99m PYP uptake pattern

Qualitative evaluation of Tc-99m PYP myocardial uptake from anterior and lateral planar images, rotating images, and reconstructed SPECT images

Text

Required

Absent

Focal

Diffuse

Focal-on-diffuse

Semi-quantitative visual grading of Tc-99m PYP uptake

Semi-quantitative interpretation of Tc-99m PYP myocardial uptake in relation to contralateral rib uptake

Text

Required

Grade 0: no uptake and normal bone uptake

Grade 1: uptake less than rib uptake

Grade 2: uptake equal to rib uptake

Grade 3: uptake greater than rib uptake with mild/absent rib uptake

Quantitative interpretation of Tc-99m PYP uptake

Quantitative cardiac Tc-99m PYP uptake using heart-to-contralateral lung (H/CL) ratio (ratio of the mean counts)

Numeric

Optional (recommended for positive scans)

XX

Blood pool activity

Qualitative evaluation of blood pool activity compared to myocardial activity

Text

Recommended (SPECT images)

Normal

Increased

Myocardial Tc-99m PYP distribution

Assess distribution of myocardial Tc-99m PYP uptake in patients with positive planar scans

Text

Optional (SPECT images)

Basal anterior (1)

Basal anteroseptal (2)

Basal inferoseptal (3)

Basal inferior (4)

Basal inferolateral (5)

Basal anterolateral (6)

Mid anterior (7)

Mid anteroseptal (8)

Mid inferoseptal (9)

Mid inferior (10)

Mid inferolateral (11)

Mid anterolateral (12)

Apical anterior (13)

Apical septal (14)

Apical inferior (15)

Apical lateral (16)

Apex (17)

Whole body planar findings

Bone findings on whole body planar images suggestive of ATTR

Text

Optional

Shoulder girdle uptake

Hip girdle uptake

Overall interpretation

Overall interpretation of findings as it relates to the diagnosis of ATTR

Text

Required

Not suggestive of ATTR

Strongly suggestive of ATTR

Equivocal for ATTR

Study quality

Image quality

Text

Required

Uninterpretable

Poor

Fair

Good

Excellent

PYP, pyrophosphate; H/CL, heart-to-contralateral lung; SPECT, single-photon emission tomography; ATTR, transthyretin amyloidosis

Coronary Artery Calcium Scoring

Coronary artery calcium score, if performed with SPECT/CT or PET/CT imaging, should be reported quantitatively and by percentile ranking based on age and sex (Table 25).49,50
Table 25

Coronary artery calcium score analysis parameters

Variable

Description

Datatype

Priority

Response

Coronary artery calcium score

Total coronary artery calcium score (sum of 4 vessels)

Numerical

Required

XX

Coronary artery calcium score by vessel

Coronary artery calcium score measured in each coronary artery

Numerical

Recommended

Left main XX

Left anterior descending XXX

Left circumflex XXX

Right coronary artery XX

Percentile ranking

Percentile ranking of total coronary artery calcium score, based on age and sex

Numerical

Recommended

XX percentile

Calcium in other areas of the heart

Qualitative assessment of calcium in the aortic valve, mitral annulus, aortic wall, pericardium, myocardium

Text

Optional

Absent calcification

Mild calcification

Moderate calcification

Severe calcification

Section on Overall Impressions

The overall impression is the most important portion of the nuclear cardiology report, as it assimilates and summarizes the most important details presented in the preceding sections. Data elements specific to this section are outlined in Table 26. Summaries of LV perfusion, function, and viability (when indicated) should be provided with clear indication of normal vs abnormal findings. For perfusion defects, a statement of whether these findings indicate ischemia, infarction, or both should be provided. This information may have been provided in preceding sections but should be highlighted in the overall impression. The number of coronary territories involved and possibly even specific vessel territories can be indicated, though caution should be advised in correlating perfusion results to coronary anatomy in the absence of prior invasive or CT coronary angiography to precisely define the epicardial distributions. For positive studies, it is recommended that a statement be made regarding the significance of the LV perfusion results. The overall impression should also contain additional statements from the body of the report if additional emphasis is needed. For instance, if transient ischemic dilation or significant RV perfusion or functional defects are present, these should be mentioned. Furthermore, to ensure timely access to the data, the report needs to be compliant with the standard for timely reporting requiring completion of the interpretation within one business day and transmittal from the lab to the referring physician within two business days.51
Table 26

Overall impression

Variable

Description

Datatype

Priority

Response

LV perfusion summary

Summary of LV perfusion

Text

Required

Normal

Probably normal

Probably abnormal

Abnormal

Equivocal

Perfusion defects

Summary of perfusion defects and clinical interpretation

Text

Required

Infarction

Ischemia

Ischemia and infarction

Peri-infarct ischemia

Probable ischemia

Probable infarction

Probable artifact

Uninterpretable

LV global function summary

Summary of global LV function

Text

Required

Normal

Low normal

Mildly reduced

Moderately reduced

Severely reduced

LV segmental function summary

Summary of LV segmental function

Text

Recommended

No regional abnormalities

Single regional abnormality

Multiple regional abnormalities

LV viability summary

Summary of the viability of LV perfusion defects if clinically indicated

Text

Optional

Substantial viability

Borderline viability

No evidence of viability

Number of diseased vessels

Number of diseased vessels

Numerical

Optional

One

Two

Three

Diseased vessels or territory

Summary of coronary vessel territory involved

 

Optional

Left anterior descending (LAD)

Left circumflex (LCX)

Right coronary artery (RCA)

ECG interpretation summary

ECG changes during stress

Text

Required

Ischemic ECG changes

Borderline ischemic ECG changes

No ischemia by ECG

ECG reported separately

ECG uninterpretable

Mildly positive

Moderately positive

Strongly positive

Strongly positive-ST elevation

Scan significance

Significance of perfusion results

Text

Recommended

Low risk

Moderate risk

High risk

Uncertain risk

Signature

Signature of interpreting MD

Text

Required

Text or electronic signature

RV perfusion summary

Summary of RV perfusion

Text

Optional

Normal

Abnormal

RV function summary

Summary of RV function

Text

Optional

Normal

Abnormal

Date signed

Date of final signature

Date

Required

mm/dd/yyyy (time optional)

Time signed

Time of final signature

Time

Optional

XX:XX:XX hours

LAD, left anterior descending; LCX, left circumflex; LV, left ventricular; RCA, right coronary artery; RV, right ventricular

Conclusion and Communication of High-Risk Results

An important additional component of the overall impression section is a combined conclusion that incorporates results from both imaging and the stress test, including the electrocardiogram, hemodynamics, and stress-induced symptoms. It is also important to note discordant results between perfusion and non-perfusion imaging results, such as normal perfusion and increased lung uptake. As detailed in Table 27, combining the results is straightforward when the ECG and imaging are concordant. Likewise, when the studies are discordant with abnormal imaging, the combined test is typically treated as abnormal. However, the combined conclusion is more challenging when there are discordant results with a positive stress ECG and negative imaging. One solution is to categorize the cardiovascular risk as low, intermediate, or high. This is difficult if the reader is not the ordering physician. Detailing supporting clinical information used to classify the risk (such as young age or atypical presentation for low risk and stress angina or high-risk ECG findings such as multiple millimeters of persistent ST depression for intermediate or high risk) can inform the referring physician of the parameters considered even when the reader has not seen the patient. A clinical recommendation can then be offered based on the risk classification. A low-risk designation could suggest that further cardiac evaluation may not be necessary. Intermediate and high-risk designations could suggest that further cardiac evaluation “could” and “should” be considered, respectively.
Table 27

Combined conclusion

Variable

Description

Datatype

Priority

Response

Combined ECG and imaging conclusion

Conclusion based on both the stress ECG and imaging findings

Text

Required

Concordant negative

Concordant positive

Discordant: ECG negative, imaging positive

Discordant: ECG positive, imaging negative

Inconclusive ECG

Inconclusive imaging

Combined Perfusion imaging and non-perfusion imaging

Conclusion based on both the perfusion imaging and non-perfusion imaging findings

Text

Recommended

Concordant negative

Concordant positive

Discordant: Perfusion images normal, non-perfusion imaging abnormal

Discordant: Perfusion images abnormal, non-perfusion imaging normal

Cardiovascular risk

Cardiovascular risk if ECG is positive but imaging is negative

Text

Optional

Low risk

Intermediate risk

High risk

Associated factors: low risk

Factors suggesting a discordant result is low risk

Text

Optional

Absence of stress-induced symptoms

Atypical clinical presentation

Few cardiovascular risk factors

High exercise workload

Low-risk stress ECG

Young age

Associated factors: intermediate risk, high risk

Factors suggesting a discordant result is intermediate or high risk

Text

Optional

Advanced age

Concerning symptoms at presentation

High-risk stress ECG

Multiple cardiovascular risk factors

Poor exercise workload

Stress-induced symptoms

Communications of high-risk results

Communications of high-risk results

Text

Required (if high-risk test results)

Text (individual’s name who was notified)

ECG, electrocardiographic

A complete report should include documentation of the communication of high-risk results, including what findings were communicated, the person to whom they were communicated, and the date and time of the communication.

A section comparing the current imaging to prior studies is recommended in all reports as shown in Table 28. The date of the study being compared should be provided, and a statement of whether there are new changes or if the imaging is unchanged. Changes in perfusion and function should be detailed, with comment on both changes in LVEF and segmental function. A statement on the clinical significance of the changes should be provided.
Table 28

Comparison to prior studies

Variable

Description

Datatype

Priority

Response

Prior study

Is there a prior study available for comparison

Text

Recommended

Yes

No

Prior study date

Date of the prior study used for comparison

Date

Recommended

mm/dd/yyyy

Prior study comparison

Comparison of the current study to prior

Text

Recommended

Unchanged

New changes

Perfusion changes

Changes in perfusion on the current study

Text

Recommended

New

Worse

Improved

Resolved

LVEF change

Changes in LVEF on the current study

Text

Recommended

Increased

Decreased

Normalized

Segmental function changes

Changes in segmental function on the current study

Text

Recommended

New

Improved

Resolved

Segmental function perfusion comparison

Comparison of function to perfusion results

Text

Recommended

Consistent with perfusion

Inconsistent with perfusion

Clinical significance

Clinical significance of new changes

Text

Recommended

Clinically significant

Clinically insignificant

Uncertain significance

Prior study date

Date of prior study

Date

Recommended

mm/dd/yyyy

LVEF, left ventricular ejection fraction

Future Directions

Available and evolving technology solutions can ameliorate the burden of comprehensive nuclear cardiology reporting and further enhance the value of the report in providing diagnostic, prognostic, and decision-guiding information, while meeting all regulatory requirements. Taking full advantage of these technology tools will facilitate evidence-based and patient-centered reporting.

Structured Reporting Software

Providing high-quality medical care and satisfying all guidelines and regulatory requirements is ever more complex; this certainly applies to nuclear cardiology reporting. Building new habits to satisfy all reporting elements is rather difficult. Using structured reporting software with hard-wired, guideline-driven reporting standards as well as built-in reminders and hard-stops for high importance reporting elements would ensure a complete and informative report every single time. Structured reporting packages can be fitted with DSTs capable of exploiting the wealth of objective clinical, stress, ECG, perfusion, functional, and ancillary data (chamber volumes, mass, and TID) to produce diagnostic and prognostic assessment using a catalogue of widely accepted nuclear cardiology literature. These determinations can be translated into hard-wired, evidence-based, and patient-centered diagnostic, prognostic, and decision-guidance statements. Furthermore, structured reporting software can facilitate reporting to accreditation bodies, automate data entry in public registries, aid in conducting research and quality improvement initiatives, and track radiation dose and critical findings.

Structured reporting software packages vary in their quality, ease of use, and comprehensiveness. They also vary in terms of their ability to auto-populate readily available data in electronic health records, previous testing reports, and stress testing data. Commonly used nuclear cardiology analysis software packages are fitted with structure reporting capabilities. Other structured reporting software can import and auto-populate imaging data from nuclear cardiology analysis packages and stress testing data from the treadmill computer console. Finally, structured reporting software may facilitate the generation of all-encompassing nuclear cardiology reports by combining separately interpreted stress and imaging data while maintaining two provider signatures: a cardiologist (stress portion) and an imaging specialist (nuclear portion). Unfortunately, structured reporting software packages are not universally used across various practice settings. ASNC recommends the use of structure reporting packages to ensure comprehensive nuclear cardiology reporting to optimize decision-making and facilitate continuous quality improvement through accreditation and public reporting.

Decision Support Tools (DST)

Computer-based DSTs can complement nuclear cardiology reporting on two main levels.
  1. (1)

    Discerning Appropriate Use: Computer-based DST can mine data readily available in electronic health records in discerning appropriateness of MPI, and when testing is rarely appropriate it can provide guidance on appropriate alternative testing, for example, exercise tolerance test (without imaging) instead of stress MPI. Deep integration of DST in the electronic order entry in electronic health information systems can provide seamless, real-time guidance on study appropriateness with minimal provider burden. AUC adherence data can then seamlessly flow into interconnected electronic structured reporting software and hence to the clinical report. Such practical technologic applications can be easily developed to enhance adherence to AUC, improve value of imaging, and facilitate compliance with PAMA requirements.

     
  2. (2)

    Risk assessment and Guiding Decision-Making: Structured reporting software can be fitted with DST that can leverage the wealth of objective clinical, stress, ECG, perfusion, functional, and ancillary data in the nuclear cardiology study to provide individualized diagnostic and prognostic statements using a catalogue of widely accepted nuclear cardiology literature. Specific examples of such statements: (1) No history of CAD or diabetes mellitus, normal exercise stress MPI and ejection fraction, and no TID: Patient is at <1% annual risk for major adverse cardiac events; (2) Abnormal MPI and abnormally high TID ratio: Perfusion imaging is predictive of multi-vessel CAD and increased risk of adverse cardiac events; (3) Normal MPI but abnormal heart rate response to vasodilator stress agent: Patient is at increased risk of mortality and adverse cardiac events; (4) Ischemic myocardial perfusion deficit 15%: observational outcome data favor coronary revascularization over medical therapy (if clinically indicated and feasible); (5) Ischemic myocardial perfusion deficit 5%: observational outcome data favor medical therapy over coronary revascularization. In such fashion, structure reporting software can be leveraged to hard-wire evidence-based and patient-centered diagnostic, prognostic, and decision-guidance statements. Decision support in nuclear cardiology reporting can be further enhanced by applying machine learning algorithms.

     

Machine Learning

The interpretation of MPI is currently performed primarily by experienced readers who mentally combine clinical, ECG, stress, perfusion, and functional data to generate an overall diagnostic and prognostic impression. However, this interpretation is primarily subjective, semi-quantitative, and heavily dependent on reader’s wealth of knowledge, acumen, and experience.52 Furthermore, traditional prognostic risk assessment in patients undergoing nuclear cardiology imaging is based on a limited menu of clinical and imaging findings. Many of these findings are continuous variables (ejection fraction, chamber volumes, TID, SSS, etc.) that are difficult to incorporate in a simple diagnostic or prognostic determination.

Machine learning can consider a greater number (dozens) and complexity of variables and correlate them with specific outcomes in very large training datasets. These machine-learned algorithms are validated in testing datasets before they can be applied clinically.53,54 Unlike multivariate regression modeling, machine learning algorithms are not fitted models, and thus are not affected by collinearity between variables. Furthermore, they can be improved in an ongoing basis incorporating accumulative observations after clinical implementation. It has been shown that machine learning algorithms derived from integrating clinical, perfusion, and functional data elements for diagnosis of obstructive CAD yield results similar to or better than those obtained by experienced readers.55 Furthermore, machine learning applications, integrating clinical, ECG, exercise, hemodynamic, defect quantification, and ancillary imaging data provide a patient-specific estimate of likelihood of early revascularization and all-cause mortality, thus aiding in individualized decision-making in a way the human brain cannot do.53,56

Machine learning algorithms are a natural complement to nuclear cardiology analyses packages and structured reporting software, from which multi-faceted data can be derived to generate risk estimates factored in DSTs and patient-centered decision guidance.

Registries and Public Reporting

ASNC’s ImageGuideTM Registry is the first registry of its kind focusing on SPECT and PET imaging. The primary purpose of the registry is quality improvement. It provides a fully integrated platform to seamlessly collect data from nuclear imaging laboratories to measure quality, safety, and efficiency. The registry contains hundreds of data elements such as referral information, demographics, clinical data, stress data, ECG data, imaging parameters, radiation dosing, perfusion, quantification, left ventricular function parameters, study quality, and signature date/time.54 Data elements in structured reporting applications within commercially available nuclear cardiology analysis packages are fully homogenized with the ImageGuideTM. Thus, data from each study can be easily submitted from the laboratory to the ImageGuideTM Registry, which in turn tracks and publicly reports, in real-time, indicators of excellence in radionuclide imaging, including crucial reporting measures.16,54,55 Such integration provides a constant quality improvement feedback loop for ever-improving report quality and patient care.57

The ImageGuideTM Registry is a Qualified Clinical Data Registry (QCDR) through which participating physicians can receive CMS reimbursement credits for participating in a Physician Quality Reporting System (PQRS). Physicians satisfactorily reporting on a minimum of 9 CMS-approved quality measures can avoid reimbursement penalties based on the Merit-Based Incentive Payment System (MIPS). Table 29 lists 2017 CMS-approved nuclear cardiology quality measures. The ImageGuideTM Registry and CMS yearly update the reported quality measures, such that old, highly achievable measures are retired and new measures are introduced in a sustained effort to continuously improve the quality of nuclear cardiology studies.
Table 29

ImageGuide TM CMS reported quality measures

1. Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients

2. Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention

3. Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

4. Utilization of standardized nomenclature and reporting for nuclear cardiology imaging studies

5. SPECT and PET-MPI studies signed within two business days

6. SPECT-MPI studies meeting appropriate use criteria

7. PET-MPI studies meeting appropriate use criteria

8. SPECT-MPI study quality excellent or good

9. PET-MPI study quality excellent or good

10. SPECT-MPI studies not Equivocal

11. PET-MPI studies not Equivocal

12. Imaging Protocols for SPECT and PET-MPI studies - Use of stress-only protocol

13. SPECT-MPI studies performed without the use of thallium

SPECT, single-photon emission tomography; PET, positron emission tomography; MPI, myocardial perfusion imaging

The appendices to this guideline demonstrate model formats for structured reporting based on the principles and data elements contained in this document. Appendices 2 and 3 are model formats for exercise stress myocardial perfusion imaging, with Appendix 3 specifically demonstrating a combined conclusion. Appendices 4 and 5 are model formats for pharmacologic-based stress myocardial perfusion imaging. They are intended as examples only and ASNC fully acknowledges that there are many allowable structured formats for the reporting of nuclear myocardial perfusion images. Different structured report formats would be required for the other indications covered in this document (e.g., PET, exercise/rest FPRNA/ERNA, and viability imaging). Appendix 6 provides a diagram of the 17-segment model with corresponding vascular territories.17

Notes

Acknowledgments

The writing group would like to recognize the input from the many reviewers who have contributed significantly to the quality of the document. We would also like to thank Victoria Anderson for her editorial and organizational skills bringing this document to completion in a timely manner.

Disclosure

Dr. Rami Doukky receives grant support and is on the advisory board of Astellas Pharma. Dr. Jamieson Bourque receives grant support from Astellas Pharma. Dr. Rupa Sanghani is on the advisory board for Astellas Pharma. All other contributors have nothing relevant to disclose.

References

  1. 1.
    Tilkemeier PL, Cooke CD, Grossman GB, McCallister BD Jr, Ward PR. ASNC imaging guidelines for nuclear cardiology procedures: Standardized reporting of myocardial perfusion images. J Nucl Cardiol 2009;16:650. doi: 10.1007/s12350-009-9095-8.CrossRefGoogle Scholar
  2. 2.
    Gonzalez P, Canessa J, Massardo T. Formal aspects of the user-friendly nuclear cardiology report. J Nucl Cardiol 1999;6:157.CrossRefGoogle Scholar
  3. 3.
    Wackers FJ. Intersocietal Commission for the Accreditation of Nuclear Cardiology Laboratories (ICANL) position statement on standardization and optimization of nuclear cardiology reports. J Nucl Cardiol 2000;7:397-400.CrossRefPubMedGoogle Scholar
  4. 4.
    Cerqueira MD. The user-friendly nuclear cardiology report: What needs to be considered and what is included. J Nucl Cardiol 1998;5:365-6.CrossRefGoogle Scholar
  5. 5.
    Kushner DC, Lucey LL. Diagnostic radiology reporting and communication: The ACR guideline. J Am Coll Radiol 2005;2:15-21.CrossRefPubMedGoogle Scholar
  6. 6.
    Tilkemeier PL, Wang TY, Lytle BL, Denton EA. Milestones: ASNC ImageGuideTM: Cardiovascular imaging data registry. J Nucl Cardiol 2013;20:1186-7.CrossRefPubMedGoogle Scholar
  7. 7.
    Ghoshhajra BB, Lee AM, Ferencik M, Elmariah S, Margey RJ, Onuma O, et al. Interpreting the interpretations: The use of structured reporting improves referring clinicians’ comprehension of coronary CT angiography reports. J Am Coll Radiol 2013;10:432-8. doi: 10.1016/j.jacr.2012.11.012.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Hendel RC, Wackers FJ, Berman DS, Ficaro E, DePuey EG, Klein L, et al. Reporting of radionuclide myocardial perfusion imaging studies. J Nucl Cardiol 2006;13:e152-6.CrossRefPubMedGoogle Scholar
  9. 9.
    Digital Imaging and Communications in Medicine (DICOM). Supplement 72: Echocardiography procedure reports. ftp://medical.nema.org/medical/dicom/final/sup72_ft.pdf. Published 18 Sep 2003. Accessed 18 Jan 2017.
  10. 10.
    Digital Imaging and Communications in Medicine (DICOM). Supplement 128: Cardiac stress testing structured reports. ftp://medical.nema.org/medical/dicom/final/sup128_ft2.pdf. Published 31 Oct 2008. Accessed 18 Feb 2017.
  11. 11.
    Integrating the Health Enterprise. IHE technical framework volume I: Integration profiles. http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev8.pdf. Published 30 Aug 2007. Accessed 18 Feb 2017.
  12. 12.
    Windle JR, Katz AS, Dow JP, Fry ETA, Keller AM, Lamp T, et al. 2016 ACC/ASE/ASNC/HRS/SCAI health policy statement on integrating the healthcare enterprise. J Am Coll Cardiol 2016;68:1348-64. doi: 10.1016/j.jacc.2016.04.017.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Douglas PS, Hendel RC, Cummings JE, Dent JM, Hodgson JM, Hoffmann U, et al. ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 health policy statement on structured reporting in cardiovascular imaging. J Am Coll Cardiol 2009;53:76-90.CrossRefPubMedGoogle Scholar
  14. 14.
    Hendel RC, Budoff MJ, Cardella JF, Chambers CE, Dent JM, Fitzgerald DM, et al. ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 key data elements and definitions for cardiac imaging: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards. J Am Coll Cardiol 2009;53:91-124.CrossRefPubMedGoogle Scholar
  15. 15.
    Trägårdh E, Hesse B, Knuuti J, Flotats A, Kaufmann PA, et al. Reporting nuclear cardiology: A joint position paper by the European Association of Nuclear Medicine (EANM) and the European Association of Cardiovascular Imaging (EACVI). Eur Heart J Cardiovasc Imaging 2015;16:272-9. doi: 10.1093/ehjci/jeu304.CrossRefPubMedGoogle Scholar
  16. 16.
    Maddux PT, Farrell MB, Ewing JA, Tilkemeier PL. Improved compliance with reporting standards: A retrospective analysis of Intersocietal Accreditation Commission Nuclear Cardiology Laboratories. J Nucl Cardiol 2016. doi: 10.1007/s12350-016-0713-y.PubMedGoogle Scholar
  17. 17.
    Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. J Nucl Cardiol 2002;9:240-5.CrossRefPubMedGoogle Scholar
  18. 18.
    Berman DS, Germano G. An approach to the interpretation and reporting of gated myocardial perfusion SPECT. In: Berman DS, Germano G, editors. Clinical gated cardiac SPECT. Armonk: Futura Publishing; 1999.Google Scholar
  19. 19.
    Port SC, Berman DS, Garcia EV, Sinusas A, Wackers F. Imaging guidelines for nuclear cardiology procedures, part 2. J Nucl Cardiol 1999;6:G47-84.CrossRefGoogle Scholar
  20. 20.
    Dilsizian V, Bacharach SL, Beanlands RS, Bergmann SR, Delbeke D, Dorbala S, et al. ASNC imaging guidelines/SNMMI procedure standard for positron emission tomography (PET) nuclear cardiology procedures. J Nucl Cardiol 2016;23:1187-226. doi: 10.1007/s12350-016-0522-3.CrossRefPubMedGoogle Scholar
  21. 21.
    Corbett JR, Akinboboye OO, Bacharach SL, Borer JS, Botvinick EH, DePuey EG, et al. Imaging guidelines for nuclear cardiology procedures: Equilibrium radionuclide angiography. J Nucl Cardiol 2009. doi: 10.1007/s12350-008-9027-z.Google Scholar
  22. 22.
    National Heart Lung and Blood Institute, Boston University. Framingham heart study: A project of the National Heart, Lung and Blood Institute and Boston University. http://www.framinghamheartstudy.org. Accessed 18 Feb 2017.
  23. 23.
    Diamond GA, Hirsch M, Forrester JS, Staniloff HM, Vas R, Halpern SW, et al. Application of information theory to clinical diagnostic testing. The electrocardiographic stress test. Circulation 1981;63:915-21.PubMedGoogle Scholar
  24. 24.
    Centers for Medicare & Medicaid Services. Qualified Provider Led Entities (PLEs) as of June 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/PLE.html. Accessed 10 July 2017.
  25. 25.
    Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, Kramer CM, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014;63(4):380-406. http://www.onlinejacc.org/content/63/4/380. Accessed 15 Mar 2017.
  26. 26.
    Doukky R, Diemer G, Medina A, Winchester DE, Murthy VL, Phillips LM, et al. Promoting appropriate use of cardiac imaging: No longer an academic exercise. Ann Intern Med 2017;166:438-40. doi: 10.7326/M16-2673.PubMedGoogle Scholar
  27. 27.
    Doukky R, Hayes K, Frogge N, Balakrishnan G, Dontaraju VS, Rangel MO, et al. Impact of appropriate use on the prognostic value of single-photon emission computed tomography myocardial perfusion imaging. Circulation 2013;128:1634-43.CrossRefPubMedGoogle Scholar
  28. 28.
    Doukky R, Frogge N, Appis A, Hayes K, Khoudary G, Fogg L, et al. Impact of appropriate use on the estimated radiation risk to men and women undergoing radionuclide myocardial perfusion imaging. J Nucl Med 2016;57:1251-7.CrossRefPubMedGoogle Scholar
  29. 29.
    Dos Santos MA, Santos MS, Tura BR, Felix R, Brito AS, De Lorenzo A. Budget impact of applying appropriateness criteria for myocardial perfusion scintigraphy: The perspective of a developing country. J Nucl Cardiol 2016;23:1160-5. doi: 10.1007/s12350-016-0505-4.CrossRefPubMedGoogle Scholar
  30. 30.
    Elgendy IY, Mahmoud A, Shuster JJ, Doukky R, Winchester DE. Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis. J Nucl Cardiol 2016;23:680-9. doi: 10.1007/s12350-015-0240-2.CrossRefPubMedGoogle Scholar
  31. 31.
    Khawaja FJ, Jouni H, Miller TD, Hodge DO, Gibbons RJ. Downstream clinical implications of abnormal myocardial perfusion single-photon emission computed tomography based on appropriate use criteria. J Nucl Cardiol 2013;20:1041-8.CrossRefPubMedGoogle Scholar
  32. 32.
    Koh AS, Flores JL, Keng FY, Tan RS, Chua TS. Correlation between clinical outcomes and appropriateness grading for referral to myocardial perfusion imaging for preoperative evaluation prior to non-cardiac surgery. J Nucl Cardiol 2012;19:277-84.CrossRefPubMedGoogle Scholar
  33. 33.
    Alexander S, Doukky R. Effective risk stratification of patients on the basis of myocardial perfusion SPECT is dependent on appropriate patient selection. Curr Cardiol Rep 2015;17:549.CrossRefPubMedGoogle Scholar
  34. 34.
    Winchester DE, Wolinsky D, Beyth RJ, Shaw LJ. Discordance between appropriate use criteria for nuclear myocardial perfusion imaging from different specialty societies: A potential concern for health policy. JAMA Cardiol 2016;1:207-10.CrossRefPubMedGoogle Scholar
  35. 35.
    Centers for Medicare and Medicaid Services. Priority Clinical Areas; Last modified: December 9, 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/PCA.html. Accessed 10 July 2017.
  36. 36.
    Doukky R, Hayes K, Frogge N, Nazir NT, Collado FM, Williams KA. Impact of insurance carrier, prior authorization, and socioeconomic status on appropriate use of SPECT myocardial perfusion imaging in private community-based office practice. Clin Cardiol 2015;38:267-73.CrossRefPubMedGoogle Scholar
  37. 37.
    Mark DB, Hlatky MA, Harrel FE Jr, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 1987;106:793-800.CrossRefPubMedGoogle Scholar
  38. 38.
    Dorbala S, Hachamovitch R, Curillova Z, Thomas D, Vangala D, Kwong RY, et al. Incremental prognostic value of gated Rb-82 Positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF. JACC Cardiovasc Imaging 2009;2:846-54. doi: 10.1016/j.jcmg.2009.04.009.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Kominsky DJ, Campbell EL, Colgan SP. Metabolic shifts in immunity and inflammation. J Immunol 2010;184:4062-8. doi: 10.4049/jimmunol.0903002.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Osborne MT, Hulten EA, Murthy VL, Skali H, Taqueti VR, Dorbala S, et al. Patient preparation for cardiac fluorine-18 fluorodeoxyglucose positron emission tomography imaging of inflammation. J Nucl Cardiol 2016. doi: 10.1007/s12350-016-0502-7.Google Scholar
  41. 41.
    Blankstein R, Waller AH. Evaluation of known or suspected cardiac sarcoidosis. Circ Cardiovasc Imaging 2016;9:e000867. doi: 10.1161/CIRCIMAGING.113.000867.CrossRefPubMedGoogle Scholar
  42. 42.
    Sciammarella MG, Gerson M, Buxton AE, et al. ASNC/SNMMI model coverage policy: Myocardial sympathetic innervation imaging: Iodine-123 meta-iodobenzylguanidine ((123)I-mIBG). J Nucl Cardiol 2015;22:804-11. doi: 10.1007/s12350-015-0202-8.CrossRefPubMedGoogle Scholar
  43. 43.
    Henzlova MJ, Duvall WL, Einstein AJ, Einstein AJ, Travin MI. ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers. J Nucl Cardiol 2016;23:606-39. doi: 10.1007/s12350-015-0387-x.CrossRefPubMedGoogle Scholar
  44. 44.
    Soman P, Travin MI, Gerson M, Cullom SJ, Thompson R. I-123 MIBG cardiac imaging. J Nucl Cardiol 2015;22:677-85. doi: 10.1007/s12350-015-0108-5.CrossRefPubMedGoogle Scholar
  45. 45.
    Flotats A, Carrió I, Agostini D, Le Guludec D, Marcassa C, Schäfers M, et al. Proposal for standardization of 123I-metaiodobenzylguanidine (MIBG) cardiac sympathetic imaging by the EANM Cardiovascular Committee and the European Council of Nuclear Cardiology. Eur J Nucl Med Mol Imaging 2010;37:1802-12. doi: 10.1007/s00259-010-1491-4.CrossRefPubMedGoogle Scholar
  46. 46.
    Falk RH, Quarta CC, Dorbala S. How to image cardiac amyloidosis. Circ Cardiovasc Imaging 2014;7:552-62. doi: 10.1161/CIRCIMAGING.113.001396.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Bokhari S, Morgenstern R, Weinberg R, Kinkhabwala M, Panagiotou D, Castano A, et al. Standardization of 99mTechnetium pyrophosphate imaging methodology to diagnose TTR cardiac amyloidosis. J Nucl Cardiol 2016. doi: 10.1007/s12350-016-0610-4.Google Scholar
  48. 48.
    Dorbala S, Bokhari S, Miller E, Bullock-Palmer R, Soman P, Thompson R. ASNC practice point: 99m technetium-pyrophosphate imaging for transthyretin cardiac amyloidosis. 2016. http://www.asnc.org/Files/Practice%20Resources/Practice%20Points/ASNC%20Practice%20Point-99mTechnetiumPyrophosphateImaging2016.pdf. Accessed 18 Feb 2017.
  49. 49.
    Dorbala S, Di Carli MF, Delbeke D, Abbara S, DePuey EG, Dilsizian V, et al. SNMMI/ASNC/SCCT guideline for cardiac SPECT/CT and PET/CT 1.0. J Nucl Med 2013;54:1485-507. doi: 10.2967/jnumed.112.105155.CrossRefPubMedGoogle Scholar
  50. 50.
    Raff GL, Abidov A, Achenbach S, Berman DS, Boxt LM, Budoff MJ, et al. SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J Cardiovasc Comput Tomogr 2009;3:122-36. doi: 10.1016/j.jcct.2009.01.001.CrossRefPubMedGoogle Scholar
  51. 51.
    Hendel RC, Ficaro EP, Williams KA. Timeliness of reporting results of nuclear cardiology procedures. J Nucl Cardiol 2007;14:266.CrossRefGoogle Scholar
  52. 52.
    Danias PG, Ahlberg AW, Travin MI, Mahr NC, Abreu JE, Marini D, et al. Visual assessment of left ventricular perfusion and function with electrocardiography-gated SPECT has high intraobserver and interobserver reproducibility among experienced nuclear cardiologists and cardiology trainees. J Nucl Cardiol 2002;9:263-70.CrossRefPubMedGoogle Scholar
  53. 53.
    Arsanjani R, Dey D, Khachatryan T, Shalev A, Hayes SW, Fish M, et al. Prediction of revascularization after myocardial perfusion SPECT by machine learning in a large population. J Nucl Cardiol 2015;22:877-84.CrossRefPubMedGoogle Scholar
  54. 54.
    Arsanjani R, Xu Y, Dey D, Vahistha V, Shalev A, Nakanishi R, et al. Improved accuracy of myocardial perfusion SPECT for detection of coronary artery disease by machine learning in a large population. J Nucl Cardiol 2013;20:553-62.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Tilkemeier PL, Mahmarian JJ, Wolinsky DG, Denton EA. ImageGuideTM update. J Nucl Cardiol 2015;22:994-7.CrossRefPubMedGoogle Scholar
  56. 56.
    Motwani M, Dey D, Berman DS, Germano G, Achenbach S, Al-Mallah MH, et al. Machine learning for prediction of all-cause mortality in patients with suspected coronary artery disease: A 5-year multicentre prospective registry analysis. Eur Heart J 2017;38:500-7. doi: 10.1093/eurheartj/ehw188.PubMedGoogle Scholar
  57. 57.
    Yadav N, Doukky R. Reporting nuclear cardiology studies: Is the cup half-full or half-empty? J Nucl Cardiol 2016. doi: 10.1007/s12350-016-0748-0.PubMedGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2017

Authors and Affiliations

  • Peter L. Tilkemeier
    • 1
  • Jamieson Bourque
    • 2
  • Rami Doukky
    • 3
    • 4
  • Rupa Sanghani
    • 4
  • Richard L. Weinberg
    • 5
  1. 1.Department of MedicineGreenville Health SystemGreenvilleUSA
  2. 2.Division of CardiologyUniversity of VirginiaCharlottesvilleUSA
  3. 3.Division of CardiologyCook County Health and Hospitals SystemChicagoUSA
  4. 4.Division of CardiologyRush University Medical CenterChicagoUSA
  5. 5.Division of CardiologyUniversity of Michigan Health SystemAnn ArborUSA

Personalised recommendations