The Evolution Of Nuclear Cardiology Takes Us Back To The Beginning To Develop Today's “New Standard Of Care” For Cardiac Imaging: How Quantifying Regional Radioactive Counts At Five And 60 Minutes Post-Stress Unmasks Hidden Ischemia

Fleming-Harrington Redistribution Wash-in Washout (FHRWW): The Platinum Standard for Nuclear Cardiology

“…As evidenced by the pathology specimen, the inflammatory plaque laid beneath the endothelial layer and was not detectable by visual inspection of the coronary lumen either by angioscopy or conventional cardiac catheterization and contrast injection. Nonetheless, this inflammatory plaque (Fleming 1999c(Fleming -d, 2000g, 2002f, 2003d(Fleming -f, 2008a(Fleming , 2009b) is physiologically responsible for angina and plaque rupture leading to death. Such individuals may be easily missed by the angiogram and stress-rest approaches; but, can be unmasked by FHRWW stress-stress imaging (Fleming 2009b) as demonstrated in this chapter.…”

“…Nonetheless, this inflammatory plaque (Fleming 1999c(Fleming -d, 2000g, 2002f, 2003d(Fleming -f, 2008a(Fleming , 2009b) is physiologically responsible for angina and plaque rupture leading to death. Such individuals may be easily missed by the angiogram and stress-rest approaches; but, can be unmasked by FHRWW stress-stress imaging (Fleming 2009b) as demonstrated in this chapter. Efforts to improve acute chest pain analysis employing FHRWW can be used to distinguish between the most critically ill individuals who will have critically narrowed arteries or arteries with vulnerable inflammatory plaques by virtue of wash-in findings defined by reduced isotope at 5 minute post pharmacologic stress imaging and normal appearing isotope concentrations at 60-minutes post-stress from those without such critical disease.…”

“…Given this information, one can calculate that over the course of 55 minutes there is a 10% decay of the isotope. In clinical studies looking at sestamibi redistribution to determine ischemia (Fleming 2009b(Fleming , 2010a) the initial stress imaging is made at 5 minutes with the second imaging at 60 minutes. An effort to improve image "sharpness" ( Figure 9A) is the result of increasing the number of pixels in a given field.…”

“…Given this spatial limitation (sharpness) versus accuracy, like Heisenberg we are left with a dilemma. Do we sacrifice accuracy for "sharpness" or should we be more concerned with the necessary accuracy required to compare images (Fleming 2009b, 2010a-b, Sheikine 2010, thereby reducing errors made in evaluation of the extent of ischemic heart disease? Now that we have defined the limitations and accuracy of our SPECT cameras to define the presence or absence of disease, we can now turn our attention to understanding the kinetics of nuclear isotopes, with particular attention to technetium-99m compounds (viz.…”

Metallic radionuclides in the development of diagnostic and therapeutic radiopharmaceuticals

“…), rich coordination chemistry, and easy availability. The huge success 1 of historical 99m Tc-radioimaging agents such as 99m Tc-sestamibi and 99m Tc-tetrofosmin for myocardial perfusion has led researchers to explore the potential of other radiometals having different physico-chemical and nuclear properties. Because of this effort, several new radiometal-based drugs have been approved by the Food and Drug Administration (FDA) and many more are in different phases of active clinical trials.…”