Dependency of cardiac rubidium-82 imaging quantitative measures on age, gender, vascular territory, and software in a cardiovascular normal population

Sunderland, John; Pan, Xiao-Bo; Declerck, Jérôme; Menda, Yusuf

doi:10.1007/s12350-014-9920-6

Cited by 29 publications

(26 citation statements)

References 25 publications

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“…1 The study found that these important flow measurements in apparently normal subjects varied substantially according to age, gender, coronary territory, and software employed. The results raise legitimate questions about whether positron emission tomography (PET) derived flow quantitation is currently sufficiently mature for inclusion in clinical imaging reports that might influence subsequent patient care.…”

Section: See Related Article Pp 72-84mentioning

confidence: 96%

Variability in normal myocardial blood flow measurements: Physiologic, methodologic, or protocol related?

Bateman

Case

2015

Journal of Nuclear Cardiology

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The current issue of the Journal of Nuclear Cardiology includes an interesting investigation that studied 3 software approaches for quantitating myocardial blood flow (MBF) and MBF reserve (MBFR) in 49 subjects who met multiple criteria for having normal cardiovascular physiology: able to exercise to a high level without chest pain or ischemic end-points, no major risk factors, and normal rubidium-82 myocardial perfusion images. 1The study found that these important flow measurements in apparently normal subjects varied substantially according to age, gender, coronary territory, and software employed. The results raise legitimate questions about whether positron emission tomography (PET) derived flow quantitation is currently sufficiently mature for inclusion in clinical imaging reports that might influence subsequent patient care.Performance of radionuclide myocardial perfusion imaging (MPI) using PET has been engendering interest and significant volume growth over the past few years. PET has been shown to offer improved image quality, interpretive certainty, and accuracy compared to both traditionally performed and attenuation-corrected single photon emission computed tomography (SPECT) MPI.2-7 PET MPI is most commonly performed with rubidium-82, a tracer that decays rapidly due to its 75 seconds half-life. Attractive attributes include throughput efficiency (rest/stress studies can be completed in about 40 minutes), low radiation exposure, 8 peak stress regional and global ventricular function comparisons against rest parameters, 9,10 and flow measurements validated against a variety of different standards. 11-20A novel capability of PET is the ability to move beyond spatially relative image interpretation to patientcentric quantitation. In a spatially relative domain, abnormality is defined in one of 3 manners: one or two myocardial regions have less tracer uptake than a best and therefore presumed normal area; the left ventricle function deteriorates with stress (e.g., transient ischemic dilation, changes between rest and stress ejection fraction); or a non-perfusion marker such as lung uptake of Tl-201 or ischemic ECG changes alert to physiologically significant CAD not detected by perfusion defect analysis alone. PET's patient-centric quantitation advances understanding about adequacy of MBF by providing an absolute measure of both global and regional blood flow at rest, at stress, and in relative terms as a ratio between stress and rest. As such, the truly unique contribution of PET is measurement of whether the myocardium is getting the blood flow necessary to meet needs, regardless of the basis for any limitation. Identified sites of blood flow compromise include the epicardial coronary arteries (local or diffuse stenoses, endothelial dysfunction/inflammation), the microcirculation, and increased epicardial-endocardial pressure gradients. These measurements have found value in improved risk stratification in varied patient populations, and for improved recognition of multi-vessel CAD. [21][22][23][24][...

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Section: See Related Article Pp 72-84mentioning

confidence: 96%

Variability in normal myocardial blood flow measurements: Physiologic, methodologic, or protocol related?

Bateman

Case

2015

Journal of Nuclear Cardiology

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“…Example of severe diffuse CAD with normal relative uptake PET images but severely reduced peak stress MBF and stress/rest MBFR, globally and for all three coronary distributions. software employed, 1,2,18,19 , and by specific vasodilator and tracer used, numerous publications report a MBFR of approximately 2 (stress/rest MBF) as a useful abnormal threshold for diagnostic and prognostic purposes. [20][21][22][23][24][25][26][27][28] However, MBFR ranges from 4.1 for the largest published series of young normal volunteers without risk factors 3,29-31 down to the ischemic threshold of 1.7 documented by angina and ECG changes during vasodilator stress [29][30][31] and further down to 1.5 associated with high risk for coronary events.…”

Section: Clinical Valuementioning

confidence: 99%

“…First, studies have shown that both gender and age affect presumed ''normal'' MBF values. 1,18 Second, there exists an array of software for quantitating MBF, incorporating differing models and assumptions; while there is less variability in MBFR measurements (since the stress/rest flow ratio cancels out some errors of absolute flow), there can be clinically significant differences in absolute values. 12,14,30,31 Third, measurement of MBF can either fail or worse, provide erroneous outputs, due to a number of technical issues such as a poor bolus, noisy data, scattered counts, incorrect placement of the blood pool regions of interest, inaccurate attenuation correction, detector saturation, and problems with myocardial definition to name a few.…”

Section: Limitations/challengesmentioning

confidence: 99%

“…Because rest MBF is affected by myocardial work, some investigators ''normalize'' the rest flows based on rest heart rate and systolic blood pressure. The PET tracers rubidium-82, O-15 water, and N-13 ammonia have all been extensively validated for flow quantitation, [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] and there now exist commercially available software for the two tracers applicable to clinical settings: rubidium-82 and N-13 ammonia. MBF and MBFR are typically measured for each myocardial pixel, and then averaged within each of 17 myocardial segments, within coronary territories, and for the entire myocardium (a ''global'' quantitation).…”

Section: Introductionmentioning

confidence: 99%

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Proceedings of the Cardiac PET Summit, 12 May 2014, Baltimore, MD

Bateman

Gould²,

Carli

2015

Journal of Nuclear Cardiology

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“…Questions have arisen as to whether the apparently wide variability in PET measurements for healthy subjects is due to variations associated with age and sex or to technical factors that augment imprecision (10,11). Optimal means for defining the input function for quantifying MBF in analyzing first-pass dynamic curves have been considered (12)(13)(14), because adequate bolus delivery can be technically challenging in some cases.…”

mentioning

confidence: 99%

Effect of Outflow Tract Contributions to ⁸²Rb-PET Global Myocardial Blood Flow Computations

Tosh

Reichek

Palestro

et al. 2016

J. Nucl. Med. Technol.

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Algorithms are able to compute myocardial blood flow (MBF) from dynamic PET data for each of the 17 left ventricular segments, with global MBF obtained by averaging segmental values. This study was undertaken to compare MBFs with and without the basal-septal segments. Methods: Data were examined retrospectively for 196 patients who underwent rest and regadenoson-stress 82 Rb PET/CT scanning for evaluation of known or suspected coronary artery disease. MBF data were acquired in gated list mode and rebinned to isolate the firstpass dynamic portion. Coronary vascular resistance (CVR) was computed as mean arterial pressure divided by MBF. MBF inhomogeneity was computed as the ratio of SD to mean MBF. Relative perfusion scores were obtained using 82 Rbspecific normal limits applied to polar maps of myocardial perfusion generated from myocardial equilibrium portions of PET data. MBF and CVRs from 17 and 14 segments were compared. Results: Mean MBFs were lower for 17-than 14-segment means for rest (0.78 ± 0.50 vs. 0.85 ± 0.54 mL/g/min, paired t test P , 0.0001) and stress (1.50 ± 0.88 vs. 1.67 ± 0.96 mL/g/min, P , 0.0001). Bland-Altman plots of MBF differences versus means exhibited nonzero intercept (−0.04 ± 0.01, P 5 0.0004) and significant correlation (r 5 −0.64, P , 0.0001), with slopes significantly different from 0.0 (−7.2% ± 0.6% and −8.3% ± 0.7% for rest and stress MBF; P , 0.0001). Seventeen-segment CVRs were higher than 14-segment CVRs for rest (159 ± 86 vs. 147 ± 81 mm Hg/mL/g/min, paired t test P , 0.0001) and stress CVR (85 ± 52 vs. 76 ± 48 mm Hg/mL/g/min, P , 0.0001). MBF inhomogeneity correlated significantly (P , 0.0001) with summed perfusion scores, but values correlated significantly more strongly for 14-than 17-segment values for rest (r 5 0.67 vs. r 5 0.52, P 5 0.02) and stress (r 5 0.69 vs. r 5 0.47, P 5 0.001). When basal segments were included in MBF determinations, perfusion inhomogeneity was greater both for rest (39% ± 10% vs. 31% ± 10%, P , 0.0001) and for stress (42% ± 12% vs. 32% ± 11%, P , 0.0001). Conclusion: Averaging 17 versus 14 segments leads to systematically 7%-8% lower MBF calculations, higher CVRs, and greater computed inhomogeneity. Consideration should be given to excluding basal-septal segments from standard global MBF determination.

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Dependency of cardiac rubidium-82 imaging quantitative measures on age, gender, vascular territory, and software in a cardiovascular normal population

Cited by 29 publications

References 25 publications

Variability in normal myocardial blood flow measurements: Physiologic, methodologic, or protocol related?

Variability in normal myocardial blood flow measurements: Physiologic, methodologic, or protocol related?

Proceedings of the Cardiac PET Summit, 12 May 2014, Baltimore, MD

Effect of Outflow Tract Contributions to ⁸²Rb-PET Global Myocardial Blood Flow Computations

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Dependency of cardiac rubidium-82 imaging quantitative measures on age, gender, vascular territory, and software in a cardiovascular normal population

Cited by 29 publications

References 25 publications

Variability in normal myocardial blood flow measurements: Physiologic, methodologic, or protocol related?

Variability in normal myocardial blood flow measurements: Physiologic, methodologic, or protocol related?

Proceedings of the Cardiac PET Summit, 12 May 2014, Baltimore, MD

Effect of Outflow Tract Contributions to 82Rb-PET Global Myocardial Blood Flow Computations

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Effect of Outflow Tract Contributions to ⁸²Rb-PET Global Myocardial Blood Flow Computations