| 1. Avoid thallium stress: No thallium stress tests were performed in patients ≤70 years old. SPECT MPI performed with thallium-201 is associated with a considerably higher radiation dose to patients than when it is performed with technetium-99m.29 This excludes thallium rest-redistribution viability studies and stress-redistribution-reinjection stress-and-viability studies. |
| 2. Avoid dual isotope: No dual isotope (rest thallium and stress technetium) stress tests were performed in patients ≤70 years old. Dual isotope MPI is associated with the highest radiation dose of any protocol.29 |
| 3. Avoid too much technetium: No study was performed with administered activity >1332 MBq (36 mCi) for an injection of technetium, and mean total effective dose was <15 mSv for all studies using just technetium injections. 1332 MBq is the highest recommended activity in guidelines,15 and 15 mSv is a high radiation dose for a study using technetium-99m. |
| 4. Avoid too much thallium: For each nuclear stress test involving thallium, no more than 129.5 MBq (3.5 mCi) was administered at stress. The expert committee maintained that no more than this activity is needed for patients who are good candidates to receive thallium MPI. |
| 5. Perform stress-only imaging: The laboratory performed at least one stress-only study, in which rest imaging was omitted, or the laboratory only does PET-based stress tests. If stress images are completely normal, subsequent rest imaging can be avoided to reduce radiation dose by up 80%. PET MPI studies have low radiation dose, the dosimetric advantage of stress-only is less, and there is less evidence regarding stress-only PET MPI. |
| 6. Use camera-based dose-reduction strategies: The laboratory performed at least one study using at least one of the following: (i) attenuation correction (CT or line source), (ii) imaging patients in multiple positions, e.g. both supine and prone, (iii) high-technology software (e.g. incorporating iterative reconstruction, resolution recovery, and noise reduction), and (iv) high-technology hardware (e.g. PET, a high-efficiency solid-state SPECT camera, or a cardiac-focused collimator). Each of these approaches reduces the radiation dose needed or facilitates performance of stress-only imaging. |
| 7. Weight-based dosing for technetium: The laboratory had a statistically significant positive correlation between patient weight and administered activity (MBq), for injections of technetium. Tailoring the administered activity to the patient size offers an opportunity to reduce radiation dose. |
| 8. Avoid inappropriate dosing that can lead to ‘shine through’ artefact: The laboratory performed no SPECT MPI studies with technetium rest and stress injections on the same day, in which activity of the second injection was <3× that of the first injection. Shine through occurs in two injection, single-day technetium studies when residual radioactivity from the first injection interferes with interpretation of images for the second injection. To avoid shine through, it is recommended in guidelines that the activity (mCi or MBq) imaged for the second injection be at least three to four times that of the first injection; in some cases, this can be achieved with a second injection that has less than four times the activity by waiting for some of the technetium-99 m to decay. Reflecting guidelines, we considered a second injection of less than three times the activity of the first injection to constitute dosing that can lead to shine through.14,15,21,30 |
| 1. Avoid thallium stress: No thallium stress tests were performed in patients ≤70 years old. SPECT MPI performed with thallium-201 is associated with a considerably higher radiation dose to patients than when it is performed with technetium-99m.29 This excludes thallium rest-redistribution viability studies and stress-redistribution-reinjection stress-and-viability studies. |
| 2. Avoid dual isotope: No dual isotope (rest thallium and stress technetium) stress tests were performed in patients ≤70 years old. Dual isotope MPI is associated with the highest radiation dose of any protocol.29 |
| 3. Avoid too much technetium: No study was performed with administered activity >1332 MBq (36 mCi) for an injection of technetium, and mean total effective dose was <15 mSv for all studies using just technetium injections. 1332 MBq is the highest recommended activity in guidelines,15 and 15 mSv is a high radiation dose for a study using technetium-99m. |
| 4. Avoid too much thallium: For each nuclear stress test involving thallium, no more than 129.5 MBq (3.5 mCi) was administered at stress. The expert committee maintained that no more than this activity is needed for patients who are good candidates to receive thallium MPI. |
| 5. Perform stress-only imaging: The laboratory performed at least one stress-only study, in which rest imaging was omitted, or the laboratory only does PET-based stress tests. If stress images are completely normal, subsequent rest imaging can be avoided to reduce radiation dose by up 80%. PET MPI studies have low radiation dose, the dosimetric advantage of stress-only is less, and there is less evidence regarding stress-only PET MPI. |
| 6. Use camera-based dose-reduction strategies: The laboratory performed at least one study using at least one of the following: (i) attenuation correction (CT or line source), (ii) imaging patients in multiple positions, e.g. both supine and prone, (iii) high-technology software (e.g. incorporating iterative reconstruction, resolution recovery, and noise reduction), and (iv) high-technology hardware (e.g. PET, a high-efficiency solid-state SPECT camera, or a cardiac-focused collimator). Each of these approaches reduces the radiation dose needed or facilitates performance of stress-only imaging. |
| 7. Weight-based dosing for technetium: The laboratory had a statistically significant positive correlation between patient weight and administered activity (MBq), for injections of technetium. Tailoring the administered activity to the patient size offers an opportunity to reduce radiation dose. |
| 8. Avoid inappropriate dosing that can lead to ‘shine through’ artefact: The laboratory performed no SPECT MPI studies with technetium rest and stress injections on the same day, in which activity of the second injection was <3× that of the first injection. Shine through occurs in two injection, single-day technetium studies when residual radioactivity from the first injection interferes with interpretation of images for the second injection. To avoid shine through, it is recommended in guidelines that the activity (mCi or MBq) imaged for the second injection be at least three to four times that of the first injection; in some cases, this can be achieved with a second injection that has less than four times the activity by waiting for some of the technetium-99 m to decay. Reflecting guidelines, we considered a second injection of less than three times the activity of the first injection to constitute dosing that can lead to shine through.14,15,21,30 |
A committee of international experts convened at the IAEA, including physicians and medical physicists, developed these criteria to be applied to nuclear cardiology laboratories.
SPECT, single-photon emission computed tomography; MPI, myocardial perfusion imaging; MBq, megabecquerel; mCi, millicurie; PET, positron emission tomography; CT, computed tomography.
| 1. Avoid thallium stress: No thallium stress tests were performed in patients ≤70 years old. SPECT MPI performed with thallium-201 is associated with a considerably higher radiation dose to patients than when it is performed with technetium-99m.29 This excludes thallium rest-redistribution viability studies and stress-redistribution-reinjection stress-and-viability studies. |
| 2. Avoid dual isotope: No dual isotope (rest thallium and stress technetium) stress tests were performed in patients ≤70 years old. Dual isotope MPI is associated with the highest radiation dose of any protocol.29 |
| 3. Avoid too much technetium: No study was performed with administered activity >1332 MBq (36 mCi) for an injection of technetium, and mean total effective dose was <15 mSv for all studies using just technetium injections. 1332 MBq is the highest recommended activity in guidelines,15 and 15 mSv is a high radiation dose for a study using technetium-99m. |
| 4. Avoid too much thallium: For each nuclear stress test involving thallium, no more than 129.5 MBq (3.5 mCi) was administered at stress. The expert committee maintained that no more than this activity is needed for patients who are good candidates to receive thallium MPI. |
| 5. Perform stress-only imaging: The laboratory performed at least one stress-only study, in which rest imaging was omitted, or the laboratory only does PET-based stress tests. If stress images are completely normal, subsequent rest imaging can be avoided to reduce radiation dose by up 80%. PET MPI studies have low radiation dose, the dosimetric advantage of stress-only is less, and there is less evidence regarding stress-only PET MPI. |
| 6. Use camera-based dose-reduction strategies: The laboratory performed at least one study using at least one of the following: (i) attenuation correction (CT or line source), (ii) imaging patients in multiple positions, e.g. both supine and prone, (iii) high-technology software (e.g. incorporating iterative reconstruction, resolution recovery, and noise reduction), and (iv) high-technology hardware (e.g. PET, a high-efficiency solid-state SPECT camera, or a cardiac-focused collimator). Each of these approaches reduces the radiation dose needed or facilitates performance of stress-only imaging. |
| 7. Weight-based dosing for technetium: The laboratory had a statistically significant positive correlation between patient weight and administered activity (MBq), for injections of technetium. Tailoring the administered activity to the patient size offers an opportunity to reduce radiation dose. |
| 8. Avoid inappropriate dosing that can lead to ‘shine through’ artefact: The laboratory performed no SPECT MPI studies with technetium rest and stress injections on the same day, in which activity of the second injection was <3× that of the first injection. Shine through occurs in two injection, single-day technetium studies when residual radioactivity from the first injection interferes with interpretation of images for the second injection. To avoid shine through, it is recommended in guidelines that the activity (mCi or MBq) imaged for the second injection be at least three to four times that of the first injection; in some cases, this can be achieved with a second injection that has less than four times the activity by waiting for some of the technetium-99 m to decay. Reflecting guidelines, we considered a second injection of less than three times the activity of the first injection to constitute dosing that can lead to shine through.14,15,21,30 |
| 1. Avoid thallium stress: No thallium stress tests were performed in patients ≤70 years old. SPECT MPI performed with thallium-201 is associated with a considerably higher radiation dose to patients than when it is performed with technetium-99m.29 This excludes thallium rest-redistribution viability studies and stress-redistribution-reinjection stress-and-viability studies. |
| 2. Avoid dual isotope: No dual isotope (rest thallium and stress technetium) stress tests were performed in patients ≤70 years old. Dual isotope MPI is associated with the highest radiation dose of any protocol.29 |
| 3. Avoid too much technetium: No study was performed with administered activity >1332 MBq (36 mCi) for an injection of technetium, and mean total effective dose was <15 mSv for all studies using just technetium injections. 1332 MBq is the highest recommended activity in guidelines,15 and 15 mSv is a high radiation dose for a study using technetium-99m. |
| 4. Avoid too much thallium: For each nuclear stress test involving thallium, no more than 129.5 MBq (3.5 mCi) was administered at stress. The expert committee maintained that no more than this activity is needed for patients who are good candidates to receive thallium MPI. |
| 5. Perform stress-only imaging: The laboratory performed at least one stress-only study, in which rest imaging was omitted, or the laboratory only does PET-based stress tests. If stress images are completely normal, subsequent rest imaging can be avoided to reduce radiation dose by up 80%. PET MPI studies have low radiation dose, the dosimetric advantage of stress-only is less, and there is less evidence regarding stress-only PET MPI. |
| 6. Use camera-based dose-reduction strategies: The laboratory performed at least one study using at least one of the following: (i) attenuation correction (CT or line source), (ii) imaging patients in multiple positions, e.g. both supine and prone, (iii) high-technology software (e.g. incorporating iterative reconstruction, resolution recovery, and noise reduction), and (iv) high-technology hardware (e.g. PET, a high-efficiency solid-state SPECT camera, or a cardiac-focused collimator). Each of these approaches reduces the radiation dose needed or facilitates performance of stress-only imaging. |
| 7. Weight-based dosing for technetium: The laboratory had a statistically significant positive correlation between patient weight and administered activity (MBq), for injections of technetium. Tailoring the administered activity to the patient size offers an opportunity to reduce radiation dose. |
| 8. Avoid inappropriate dosing that can lead to ‘shine through’ artefact: The laboratory performed no SPECT MPI studies with technetium rest and stress injections on the same day, in which activity of the second injection was <3× that of the first injection. Shine through occurs in two injection, single-day technetium studies when residual radioactivity from the first injection interferes with interpretation of images for the second injection. To avoid shine through, it is recommended in guidelines that the activity (mCi or MBq) imaged for the second injection be at least three to four times that of the first injection; in some cases, this can be achieved with a second injection that has less than four times the activity by waiting for some of the technetium-99 m to decay. Reflecting guidelines, we considered a second injection of less than three times the activity of the first injection to constitute dosing that can lead to shine through.14,15,21,30 |
A committee of international experts convened at the IAEA, including physicians and medical physicists, developed these criteria to be applied to nuclear cardiology laboratories.
SPECT, single-photon emission computed tomography; MPI, myocardial perfusion imaging; MBq, megabecquerel; mCi, millicurie; PET, positron emission tomography; CT, computed tomography.
This PDF is available to Subscribers Only
View Article Abstract & Purchase OptionsFor full access to this pdf, sign in to an existing account, or purchase an annual subscription.
