Clinical Nuclear Cardiology: State of the Art and Future Directions: Expert Consult: Online and Print, 4e

Front Cover
Title Page
Copyright
Dedication
Contributors
Preface
Section 1: Radiopharmaceuticals/Tracer Kinetics
	1 Overview of Tracer Kinetics and Cellular Mechanisms of Uptake
		Introduction
		Cellular Uptake Of Myocardial Perfusion Agents
			Thallium-201
			Monovalent Cationic Technetium-99m-Labeled Tracers
			Neutral Lipophilic Tracers
		Modeling Tracer Extraction
		Tracer Retention
		Redistribution
			The Mechanism
			Redistribution Versus Persistent Defect
			Reinjection (See Chapter 37)
			Tracers That Do Not Redistribute
			Reverse Redistribution
		Detection Of Coronary Artery Disease
		Myocardial Viability (See Chapters 37-39)
		Acute Coronary Syndrome
		Reduced Flow Reserve And \"Balanced Ischemia\" (See Chapter 23)
		Summary
		References
	2 Principles of Myocardial Metabolism as They Relate to Imaging
		Introduction
		Overview Of Metabolic Regulation In The Normal Heart
			Fatty Acid Metabolism
			Glucose Metabolism
			Tricarboxylic Acid Cycle Metabolism and the Electron Transport Chain
		Metabolic Tracers
		Metabolic Responses To Disease States
			Myocardial Ischemia
			Congestive Heart Failure
			Diabetes
			Renal Disease
		Future Targets For Metabolic Imaging
		References
	3 Role of Intact Biological Models for Evaluation of Radiotracers
		Introduction
		Selection Of Animal Model
			Use of Small Mammals for Definition of Biodistribution
			Use of Small Mammals for Evaluation of Specific Disease Processes (See Chapter 11)
			Use of Genetically Engineered Small Mammals for Evaluation of Specific Biological Processes and Radiotracers (See Chapter 45)
			Use of Large Mammals for Evaluation of Specific Disease Processes
		Selection Of Anesthesia
		Methods Of Measurement
			Dynamic Imaging
				Planar Imaging
				Single-Photon Emission Computed Tomography
				Positron Emission Tomography (See Chapter 11)
			Miniature Detectors
			Serial Myocardial Biopsy
			Postmortem Imaging
			Autoradiography
				Microautoradiography
				Macroautoradiography
			Postmortem Tissue Well Counting
			Evaluation of Tracer Kinetics and Kinetic Modeling
		Physiologic Models
			Myocardial Infarction
			Myocardial Stunning
			Myocardial Hibernation (See Chapter 36)
			Dilated Cardiomyopathy
			Atherosclerosis (See Chapter 44)
		Models Of Plaque Rupture
		Models Of Aortic Aneurysms
		Short-Term And Long-Term Models
		Evaluation Of Pharmacologic Stressors
		Conclusions
		References
Section 2: Instrumentation
	4 SPECT Processing, Quantification, and Display
		Introduction
		Oblique Reorientation And Reslicing
		Motion Correction (See Chapter 5)
		Automated Perfusion Quantification
			Myocardial Isolation and Sampling
			Normal Databases and Criteria for Abnormality
			Quantitative Parameters
			Commercial Implementations
			New Databases
		Display
			Polar Maps
			Three-Dimensional Displays
		Artificial Intelligence Techniques Applied To Spect
			Expert System Analysis of Perfusion Tomograms
			Neural Networks
			Data Mining
			Commercial Implications
		Assessment Of Serial Studies
		Fusion Of Multimodality Cardiac Imagery
			Registration of Myocardial Perfusion and Magnetic Resonance Images
			Registration of Myocardial Perfusion Images and Coronary Artery Data from Angiography
			Fusion of Myocardial Perfusion Images and CT Angiography (See Chapter 8)
		Phase Analysis Of Gated Myocardial Perfusion Spect Images
			Mathematical Principles in Phase Analysis
			Processing and Quantification of Dyssynchrony
			Reproducibility
			Temporal Resolution
		Conclusion
		References
	5 Single-Photon Emission Computed Tomography Artifacts
		Introduction
		Technical Artifacts
			Flood Field Nonuniformity
			Center of Rotation and Camera-Held Alignment Errors
			Errors in Selecting Oblique Cardiac Axes and Subsequent Polar Map Reconstruction
			Selection of Apex and Base for Polar Map Reconstruction
			Arrhythmias and Gating Errors
		Patient-Related Artifacts
			Soft-Tissue Attenuation (See Chapters 6 and 7)
			Breast Attenuation
			Lateral Chest-Wall Fat Attenuation
			Diffuse Depth-Dependent Soft-Tissue Attenuation
			Diaphragmatic Attenuation
		Apparent Worsening Of Attenuation Artifacts In Low-Dose Rest Images
		Advantages And Potential Disadvantages Of Attenuation Correction In Resolving Attenuation Artifacts (See Chapters 6 and 7)
		Scattered Abdominal Visceral Activity
		The Ramp Filter Artifact
		Motion Artifacts (See Chapter 4)
		Artifacts Related To Noncoronary Heart Disease
			Myocardial Hypertrophy
			Left Bundle Branch Block (See Chapter 16)
		Summary
		References
	6 Attenuation/Scatter/Resolution Correction: Physics Aspects
		Introduction
		Impact Of Attenuation, Scatter, And Resolution On Cardiac Single-Photon Emission Computed Tomography (See Chapter 7)
			Interactions and Exponential Attenuation
			Attenuation Artifacts (See Chapter 6)
			Broad Beam Attenuation and Scatter
			Finite and Distance-Dependent Spatial Resolution
		Estimation Of Patient-Specific Attenuation Maps
			Basic Transmission Configurations
		Attenuation Correction Methods
			Statistically Based Reconstruction Methods
		Scatter Correction Methods
		Spatial Resolution Compensation Methods
		Example Observer Studies Illustrating The Utility Of Compensation
		Conclusions
		Acknowledgments
		References
	7 Attenuation Correction and Scatter Correction of Myocardial Perfusion SPECT Images
		Introduction
		Historical Perspective
		Scientific Foundation Of Attenuation: Compton Scattering And The Photoelectric Effect (See Chapter 6)
		Physics Of Attenuation And Scatter Compensation
		Techniques Of Acquiring The Patient-Specific Attenuation Map
			Line Source Attenuation Correction
			Computed Tomography-Based Attenuation Correction
			Quality-Control Issues
		Applications For Attenuation Correction
			Stress Only
			Acute Imaging
			Quantitative Single-Photon Emission Computed Tomography
		Challenges For Attenuation Correction
		Conclusion
		References
	8 Hybrid Cardiac Imaging
		Introduction (See Chapter 22)
		Technical Considerations Of Hybrid Imaging
		Hybrid Imaging: Comprehensive \"One-Stop Shop\"
		Value Of Hybrid Imaging For Attenuation Correction
		Prognostic And Diagnostic Value Of Coronary Artery Calcium Scores (See Chapter 20)
		Hybrid Scanners Versus Hybrid Imaging
		Perspectives Of Hybrid Imaging
		References
	9 Digital/Fast SPECT: Systems and Software
		Introduction
		Dedicated Cardiac Imaging Systems
			Digirad Cardius 3 XPO
			CardiArc
			Spectrum Dynamics
			Multipinhole Systems
		Fast Myocardial Perfusion Imaging Software With Standard Systems
			Astonish
			GE Healthcare\'s Evolution Software
			Siemens Medical Solutions
			UltraSPECT Wide Beam Reconstruction
			Motion-Frozen Reconstruction
		Conclusions
		Acknowledgments
		References
	10 Radiation Considerations for Cardiac Nuclear and Computed Tomography Imaging
		Introduction
		Radiation Dosimetry
			Fundamentals, Definitions, and Quantities
			Environmental Sources of Radiation Exposure
			Radiation Dosimetry of Single-Photon Emission Computed Tomography Myocardial Perfusion Tracers
			Radiation Dosimetry for Cardiac Positron Emission Tomography Tracers
		Models For Radiation Risk
			The Linear No-Threshold Model for Radiation Risk
			Attributable Lifetime Risk from Radiation Exposure
			Occupational Radiation Exposure and Limitations
			\"As Low As Reasonably Achievable\" Principle
		Computed Tomography (See Chapter 21)
			CT Radiation Dosimetry: Fundamentals, Definitions, and Quantities
			Dose Reduction Techniques for Cardiac Computed Tomography
				Tube Current Modulation
				ECG-Pulse Modulation
				Organ and Breast Shielding
			Dosimetry Values for Cardiac CT Procedures
		X-Ray And Radionuclide Source-Based Radiation Exposure For Pet And Spect Attenuation Correction
		Summary
		References
	11 State-of-the-Art Instrumentation for PET and SPECT Imaging in Small Animals
		Introduction
		Micro-Positron Emission Tomography
		Positron Emission Tomography Imaging Of The Rodent Heart
		Imaging The Cardiovascular System In Mice And Rats
			Experimental Coronary Occlusions in the Rat
			Studies in Genetically Modified Mice
			Development of Novel Radiotracer Assay Approaches
			Quantification of Functional Processes
				Measurements of Myocardial Activity Concentrations
				Assays of Time-Dependent Changes in Tissue Activity Concentrations
				Measurements of Absolute Blood Flow in the Myocardium of Rats
				Semiquantitative Estimates of Changes in Myocardial Blood Flow in Mice
			Limitations and Challenges
		Micro-Single-Photon Emission Computed Tomography
			MicroSPECT Instrumentation
			Uses of MicroSPECT Instrumentation for Cardiovascular Molecular Imaging
				Myocardial Perfusion and LV Function
				Quantitative Assessment of Myocardial Viability Using Technetium-99m-Glucarate
				Dual-Isotope Imaging of Myocardial Perfusion and Inflammation
				Monocyte Trafficking in Atherosclerosis
				Imaging Matrix Metalloproteinase Expression in Vascular Remodeling
			Limitations and Challenges
		References
Section 3: Ventricular Function
	12 Cardiac Performance
		Introduction
		Equilibrium Radionuclide Angiocardiography
			Technical Issues
			Gated Blood Pool Single-Photon Emission Computed Tomography
			Performance
			Phase Imaging
			Ambulatory Monitoring
			First-Pass Radionuclide Angiocardiography
			Shunt Detection
			Comparison of First-Pass and Equilibrium Techniques
		Clinical Applications
			Resting Ventricular Performance
			Coronary Artery Disease
			Exercise Studies
			Silent Myocardial Ischemia
			Valvular Heart Disease
			Congestive Heart Failure
			Chronic Obstructive Pulmonary Disease
		References
	13 Regional and Global Ventricular Function and Volumes from SPECT Perfusion Imaging
		Introduction
		Acquisition
			Importance of \"Bad Beat\" Rejection
				Cardiac Beat Length Acceptance Window as a Tool for \"Bad Beat\" Rejection
				Gating Errors
		Processing
		Quantification
			The Cedars-Sinai Approach: Quantitative Gated SPECT
			The Emory University Approach: Emory Cardiac Toolbox
			The University of Michigan Approach: 4D-MSPECT
			The Yale University Approach
		Ejection Fraction
		End-Systolic and End-Diastolic Volume
		Regional Systolic Function
		Diastolic Function
		Phase Analysis
		Right Ventricular Function
		Blood Pool Spect
		Diagnostic Value of Gated Spect
		Prognostic Value of Gated Spect
		Assessing Myocardial Viability
		References
Section 4: Perfusion Imaging
	14 Coronary Artery Disease Detection
		Introduction
		Physiology of Exercise Stress Testing
		Exercise Protocols
		Preparation for Exercise
		Basis of Stress Imaging
		Injection of Radiotracer
		Imaging Protocols
		Diagnostic Value of Exercise Spect Imaging
		Ecg-Gated Spect
		Motion Correction
		State-of-the-Art Myocardial Perfusion Spect with Attenuation Correction
		Display of Exercise Spect Images
		Semiquantitative Visual Analysis and Quantitative Analysis of Myocardial Perfusion Images
		Interpretation of Exercise Spect Studies
		Image Interpretation
		Low-risk and high-risk Image Patterns
			Low-Risk Patterns
			High-Risk Patterns
		Reporting Spect Imaging Results
		References
	15 Coronary Artery Disease Detection
		Introduction
		Pharmacology
			Adenosine
			Dipyridamole
			Dobutamine
		Myocardial Blood Flow
			Myocardial Blood Flow in Normal Patients
			Myocardial Blood Flow with Modified Pharmacologic Stress Protocols
			Myocardial Blood Flow in Patients with CAD
		Myocardial Blood Flow and Perfusion Imaging
		Perfusion Imaging Protocols
		Safety and Side Effects
		Hemodynamic Effects
			Vasodilators
			Dobutamine
		Ischemic Response
			Vasodilators
			Dobutamine
		Lung Thallium Uptake
		Transient Ischemic Dilatation
		Poststress Left Ventricular Dysfunction
		Diagnosis of Coronary Artery Disease
			Vasodilators
			Dobutamine
			Comparison of Pharmacologic Myocardial Perfusion Imaging
			Comparison to Exercise
			Results in Women
			Detection of Left Main or Three-Vessel Disease
		Hybrid Protocols
			Abbreviated Adenosine Protocols
			Vasodilators and Exercise
			Modified Dobutamine Protocols
		Special Patients
			Patients With Left Bundle Branch Block
			Patients with Permanent Ventricular Pacing
			Patients with Left Ventricular Hypertrophy or Cardiomyopathy
		Effect of Anti-Ischemia Medications
		New Agent Development
			Binodenoson
			Regadenoson
		Summary
		References
	16 Prognostic Implications of MPI Stress SPECT
		Introduction
		Principles of Risk Stratification: Patient Selection and Metrics of Risk
			Risk of Adverse Events After a Normal Imaging Study
			Relationship Between Risk and the Extent and Severity of Imaging Results
			Added Value of Gated SPECT
		Use of mps in Specific Patient Populations
			Patient Cohorts Defined by CAD Likelihood and ECG Criteria
				Patients With an Intermediate Likelihood of CAD or Indeterminate Treadmill Test
				Patients With Normal Resting ECG Able to Exercise
				Patients With Normal Resting ECG Unable to Exercise
				Patients With High Pretest Likelihood of CAD
				Patients With Left Bundle Branch Block (See Chapter 5)
				Patients With LVH or Atrial Fibrillation
			Patient Cohorts Defined by Risk Factors and Demographics
				Asymptomatic Patients
				Nuclear Imaging in Patients With Diabetes Mellitus
				Gender-Based Differences in the Prognostic Value of MPS
				Nuclear Imaging in Elderly Patients
				MPS in Patients With Chronic Kidney Disease
				MPS in Ethnic Minority Patients
				Evidence Supporting Nuclear Imaging for Obese Patients
			MPS After Other Noninvasive Testing
				MPS After Coronary Calcium Screening or Coronary CT Angiography  (See Chapter 20)
			MPS in Patients with Prior CAD
				Patients After Percutaneous Coronary Intervention
				Evidence Supporting Nuclear Testing for Patients After CABG
		Use of mps in Guiding Decisions for Catheterization
		Estimating the True Prognostic value of mps and Posttest Referral Bias
		Incremental Prognostic value of Pre-mps Data
			Understanding and Estimating Posttest Risk
			The Need for Imaging Scores in Risk Estimation and Reporting
		Using mps for Medical Decision Making: Identifying risk Versus Identifying Potential Survival Benefit
			Imaging in the Post-COURAGE Era
			New Paradigm: The Added Value Of a Modality Is Its Ability to Identify Candidates for Expensive Rx Resulting in Enhanced Clini.
			Where and When Will MPS be Used?
			Important Questions to Help Define the Role and Value of MPS
		Conclusions
		References
	17 Myocardial Perfusion
		Introduction
		Basic Principle of Image Preparation and Acquisition
		Approaches to Image Analysis
			Semiquantitative Perfusion Cardiac Magnetic Resonance
			Fully Quantitative Perfusion CMR
		Future Directions
			Nephrogenic Systemic Fibrosis
		Conclusions
		References
	18 Myocardial Perfusion Imaging with Contrast Echocardiography
		Introduction
		Ultrasound Contrast Agents
		Imaging Microbubbles in Tissue
		Quantification of Myocardial Blood Flow
		Myocardial Contrast Echocardiography for Cad Detection
		Mce in acute Myocardial Infarction
		Assessment of Myocardial Viability
		Summary
		References
	19 Diagnosis and Prognosis in Cardiac Disease Using Cardiac PET Perfusion Imaging
		Introduction
		Practical Aspects of imaging and Analysis
			General Principles of PET Imaging
			Myocardial PET Perfusion Tracers
				Nitrogen-13 Ammonia
				Rubidium-82
				Oxygen-15 Water
				Carbon-11-Acetate
				Cu-62 PTSM, Cu-62 ETS
			Recent Advances in PET Imaging: Novel Myocardial Blood Flow Tracers
		Myocardial Imaging Protocols and Acquisition
			Patient Preparation
			Stress Testing Protocols
			Myocardial Perfusion Imaging Protocols
				13N Ammonia
				82Rubidium
			Image Evaluation for Technical Sources of Errors: Quality Control
			Image Analysis and Interpretation of Perfusion Images
		Absolute Myocardial Blood Flow Quantification
			Advantages of Absolute Quantitative Analysis
			Models for Flow Quantification
			Three-Dimensional Imaging Mode for Absolute Blood Flow Quantification
			Radiotracers and Myocardial Blood Flow Quantification
				Oxygen-15-Water
				Nitrogen-13-Ammonia
				Rubidium-82
			Physiologic Parameters for Absolute Quantification
		Fusion of Structure and Function: Insights of Integrated Pet/ct Systems
		Clinical Applications for Myocardial Perfusion Imaging with pet
			Selection of Patients
			Diagnosis of Coronary Artery Disease
			Prognosis of Coronary Artery Disease
		Potential Clinical Applications of Pet Absolute Quantification
			Preclinical Diagnosis of Cardiovascular Disease
				Significance of Endothelial and Microvessel Dysfunction
				Methods to Assess Microvascular Structure and Function
				Functional Significance of Cardiovascular Risk Factors on MBF and CFR
			Myocardial Blood Flow Parameters in Established Cardiovascular Disease
			Myocardial Blood Flow Parameters in Nonatherosclerotic Microvascular Disease
			Myocardial Blood Flow Parameters as Surrogate Markers
				MBF and CFR for the Follow-up of Current Medical Managements
				MBF and CFR for the Assessment of Interventional Therapies
				Myocardial Blood Flow Parameters and Novel Therapeutic Approaches
			Hybrid Imaging: Fusion Images of CTA and MBF
		Summary and Conclusions
		References
	20 Coronary Artery Calcification
		Introduction
		Types of Arterial Calcification
		Pathogenesis of Coronary Artery Calcification
			Clinical Relevance of Coronary Artery Calcification
			Biochemical Factors Implicated in Coronary Calcification
		Coronary Artery Calcium Imaging using Electron Beam Computed Tomography/Multislice Computed Tomography
		Algorithms for Quantification of Coronary Calcium
			Agatston Score
			Volume Score
			Mass Score
			Coronary Artery Calcium Score: What Does It Mean?
		Role of cac Imaging in risk Stratification
			The Significance of Risk Stratification in Coronary Artery Disease
			Correlation Between Coronary Artery Calcium and Conventional Cardiovascular Risk Factors
			Who Should Undergo CAC Screening?
		The Prognostic Value of cac: Available Evidence
			Limitations of CAC Imaging as a Screening Tool in the General Population
			Role of CAC Imaging in the Diagnosis of CAD in Symptomatic Patients
		Comparison of cac with other Diagnostic Tests
			CAC and Stress Electrocardiography
			CAC and Myocardial Perfusion Scintigraphy: Role of Synergistic Imaging
			CAC and Other Stress Tests
		Proposed Algorithm for Sequential Screening
		Cac Imaging in Patients with Diabetes Mellitus and Cardiometabolic Syndrome
		Effect of Ethnicity on Prevalence and Prognostic Significance of Coronary Calcium
		Progression of Coronary Calcium-Causes and Consequences
		Effect of Treatment on Progression of Coronary Calcium
		Cost-Effectiveness of cac Imaging
		Future Directions: can ct Coronary Angiography Replace cac Imaging?
		References
	21 Coronary Artery Computed Tomography Angiography
		Introduction
		Computed Tomography Coronary Artery Angiography: Technologic Considerations
		Comparison of Coronary Computed Tomography Angiography with Invasive Angiography for the Detection of Luminal Stenosis
			Native Coronary Arteries (Figs. 21-4 and 21-5)
			Coronary CTA for Evaluation of Bypass Grafts (Fig. 21-6)
			Coronary CTA for Evaluation of Coronary Stent Patency (Fig. 21-7)
		Coronary Computed Tomography Angiography: Comparison with Nuclear Myocardial Perfusion Imaging
		Coronary Computed Tomography Angiography to Perform Myocardial Perfusion Imaging and Assess Viability
		Assessment of Left Ventricular Function and Mass by Cardiac Computed Tomography
		Prognosis of Patients Undergoing Computed Tomography Angiography to Diagnose Coronary Artery Disease
		Other uses of Computed Tomography Angiography
			Noncalcified Atherosclerotic Plaque
			Coronary Artery Anomalies
			Guidance Prior to Attempting Angioplasty of a Chronic Total Occlusion
			Presurgical Risk Stratification
			Assessment of Etiology of Left Ventricular Dysfunction
		Radiation Exposure (See Chapter 10)
		When Should Coronary Computed Tomography be Utilized?
		Acknowledgements
		References
	22 PET/CT and SPECT/CT Hybrid Imaging
		Introduction
		Rationale for Integrating Nuclear Imaging and ct
			Myocardial Perfusion Imaging (See Chapters 14-16)
			Cardiac Computed Tomography (See Chapter 21)
		Clinical Applications of Dual-Modality Imaging
			Attenuation Correction (See Chapters 6 and 7)
			Localization of Targeted Molecular Imaging Agents
			Integrating Calcium Scoring with Myocardial Perfusion Imaging
			Integrating CT Coronary Angiography and Myocardial Perfusion Imaging for Diagnosis and Management of CAD
		Challenges, Potential Opportunities, and Unresolved Issues for Hybrid Imaging
			Single-Setting Dual-Modality Versus Sequential Imaging
			Radiation Dosimetry
		Conclusions
		References
	23 Comparison of Noninvasive Techniques for Myocardial Perfusion Imaging
		Introduction
		Radionuclide Myocardial Perfusion Imaging (See Chapters 14 to 16)
		Positron Emission Tomography (See Chapter 19)
		Cardiac Magnetic Resonance Perfusion Imaging (See Chapter 17)
		Computed Tomography Perfusion Imaging
		Perfusion Imaging with Myocardial Contrast Echocardiography (See Chapter 18)
		Summary
		References
	24 Cost-Effectiveness of Myocardial Perfusion Single-Photon Emission Computed Tomography
		Introduction
		Health Care Costs for Cardiovascular Disease
		Evaluating Procedural Cost
			Adding Downstream Costs
		Defining Incremental Effectiveness
		Defining Incremental Cost-Effectiveness Ratio
		Use of Intermediate Outcome Measures
			High-Risk Cost-Effectiveness Models
		Economic Impact of Nuclear Cardiology as a Gatekeeper to the Diagnostic Catheterization laboratory
			Cost Minimization or Savings
			Cost-Effectiveness of Myocardial Perfusion SPECT Compared to Other Diagnostic Procedures
			American Society of Nuclear Cardiology Statement on Cost-Effectiveness of Nuclear Cardiology
		Conclusions
		References
	25 Appropriate Use of Nuclear Cardiology
		References
Section 5: Disease/Gender-Specific Issues
	26 Imaging in Women
		Introduction
		Diagnosing Coronary Artery Disease In Women
			Exercise Tolerance Testing
			Stress Myocardial Perfusion Imaging in Women
			Pharmacologic Myocardial Perfusion Imaging (See Chapter 15)
		Gender-Related Challenges in the Diagnosis of Coronary Artery Disease
		Risk Stratification in Women (See Chapter 16)
		Conclusions
		References
	27 Imaging for Preoperative Risk Stratification
		Introduction
		Step One: Determine the Urgency of the Surgery
		Step Two: Evaluate and Treat Active Cardiac Conditions
		Step Three: Determine Whether the Planned Procedure is low-risk Surgery
		Step Four: Assess Functional Capacity
		Step Five: Assess Clinical Risk in Symptomatic Patients or Patients with Poor/Unknown Functional Capacity
			Clinical Risk Score
			Surgical Risk
			Vascular Surgery
			Transplant Surgery
		The Decision to Obtain Preoperative Testing: a Shortcut Approach
		Risk Assessment with Preoperative Stress Imaging
		Perioperative Medical Treatment
		Coronary Angiography and Revascularization
		Long-term Prognosis after Noncardiac Surgery
		Utilizing Preoperative Testing for Long-term Prognosis
		Conclusion: use of Guidelines for cost-effective Risk Assessment
		References
	28 Nuclear Imaging in Revascularized Patients with Coronary Artery Disease
		Background
		Evaluation After Coronary Artery Bypass Graft
			Detection of Graft Disease
			Anatomy Versus Physiology Considerations
			Prognostic Implications of Stress Nuclear MPI after CABG
			Assessment Early After CABG (2 to 3 Years)
			Assessment Late After CABG (Beyond 5 Years)
		Evaluation After Percutaneous Coronary Intervention
			Early After PCI
			3 to 6 Months After PCI
			Late After PCI
				Time Dependency of Risk
		Novel Revascularization Methods and Research Trends
		Summary
		References
	29 Stress Myocardial Perfusion Imaging in Patients with Diabetes Mellitus
		Introduction
		Early Detection of Coronary Artery Disease in Diabetes Mellitus
			Stress Modality
			Prevalence of Silent Myocardial Ischemia
			Endothelial Dysfunction
		Abnormal Myocardial Perfusion Imaging in Patients with Suspected or Known Coronary Artery Disease (See Chapter 16)
		Clinical Predictors of Silent Myocardial Ischemia
		Multimodality Approach for Detection of cad in Diabetes Mellitus (See Chapter 20)
		Treatment of Silent Myocardial Ischemia in Patients with Diabetes
		References
	30 Radionuclide Imaging in Heart Failure
		Introduction
		Established uses of Radionuclide Imaging in Heart Failure
			Determining Heart Failure Etiology
			Measuring Left Ventricular (Dys)Function (See Chapters 12 and 13)
			Predicting Benefit from Coronary Revascularization: Assessment of Myocardial Viability (See Chapters 37 and 38)...
		Evolving Applications of Radionuclide Techniques in Heart Failure
			Targeted Molecular Imaging and Imaging Myocardial Metabolism (See Chapters 40 and 41)
				Imaging Cellular Mechanisms in Heart Failure
			Assessing LV Remodeling: Shape Indices
			Assessment of LV Mechanical (Dys)Synchrony
		Conclusion
		References
	31 Imaging in Patients Receiving Cardiotoxic Chemotherapy
		Introduction
		Mechanisms of Cardiotoxicity
		Pathology
		Incidence of Cardiotoxicity
		Clinical Course
		Monitoring for Cardiotoxicity
		Trastuzumab (Herceptin) Cardiotoxicity
		References
	32 Mechanistic and Methodological Considerations for the Imaging of Mental Stress Ischemia
		Introduction
		Mental Stress Ischemia
			Evidence Base for MSI-An Historical Perspective
			ECG Changes During Mental Stress
			Left Ventricular Dysfunction During Mental Stress
				Studies Using Radionuclide Angiography
				Studies Using Echocardiography
			Myocardial Perfusion During Mental Stress
			Comparison Between Mental Stress Imaging and Standard Exercise and Pharmacologic MPI
			Prognostic Significance of Myocardial Stress Ischemia
			Psychological Factors and Prognosis in Mental Stress Ischemia
		Pathophysiology of Mental Stress Ischemia
			Mental Stress and Vascular Function
			Mental Stress and Inflammation
				Cholinergic Antiinflammatory Reflex
			Neurocardiac Central Nervous System Correlates
				Functional PET Brain Imaging
				Imaging of Cardiac Neuronal Integrity
		Mental Stress and Disease-Emerging Areas
			Takotsubo Cardiomyopathy
			Electrophysiologic Abnormalities and Arrhythmic Heart Disease
		Suggested Protocol for Mental Stress Spect
			Imaging
			Mental Stress Protocol
			Processing and Interpretation
		Conclusion
		References
	33 Myocardial Blood Flow Measurement: Evaluating Coronary Pathophysiology and Monitoring Therapy
		Introduction
		Methodology of Blood Flow Measurement
		Pet Tracers of Myocardial Blood Flow (See Chapter 19)
			13N-Ammonia
			Rubidium-82
			15O-Water
		Determinants of Myocardial Blood Flow and Flow Reserve
			Coronary Circulatory Function: Definitions
		Noninvasive Assessment of Coronary Circulatory Function
			Myocardial Blood Flow at Rest
			Assessment of Coronary Reactivity
			Total Integrated Vasodilator Capacity and Coronary Flow Reserve
			Sympathetic Stimulation with Cold Pressor Testing
			Perfusion Heterogeneity and Base-to-Apex Myocardial Perfusion Gradient
			Reproducibility of Measurements of Myocardial Blood Flow and Responses to Stressors
		Altered Coronary Circulatory Function and Cardiovascular Events
			Insights Into Mechanisms of Coronary Circulatory Dysfunction by PET
				Vascular Inflammatory States
				Smoking, Vascular Oxidation-Reduction State, and Hypertension
				Obesity, Insulin-Resistance, and Adipocytokines
		Delineation of Coronary risk and Monitoring of Therapeutic Strategies
			Hormone Replacement Therapy in Postmenopausal Women
			Responses to Lipid-Lowering Treatments
			Insulin Resistance, Impaired Glucose Tolerance, and Diabetes Mellitus
		Summary and Future Directions
		Acknowledgments
		References
Section 6: Acute Coronary Syndromes
	34 Imaging Patients with Chest Pain in the Emergency Department
		Introduction
		Acute Myocardial Perfusion Imaging
		Diagnostic Value
			Sensitivity in Acute Myocardial Infarction
			Acute Coronary Syndrome Without Myocardial Infarction
		Negative Predictive Value and Prognosis
		Incremental Diagnostic Value
		Cost-Effectiveness
			Comparison with Troponin
		Risk Area
		Other Issues
			Radiopharmaceuticals
			Timing of Tracer Injection
			Special Populations
		Limitations of Acute Myocardial Perfusion Imaging
		Incorporation Into Emergency Department Chest-Pain Evaluation
		Summary
		References
	35 Risk Stratification after Acute ST-Segment Elevation and Non-ST-Segment Elevation Myocardial Infarction
		Introduction
		Clinical Predictors of Risk
		Imaging Predictors of Risk
			Infarct Size
			Left Ventricular Ejection Fraction
			Left Ventricular Volumes
			Myocardial Ischemia
		Risk Stratification Following Acute Myocardial Infarction
			Exercise Stress Testing
			Gated Radionuclide Angiography
			Exercise Myocardial Perfusion Scintigraphy
			Pharmacologic Stress Perfusion Scintigraphy
				Dipyridamole SPECT
				Adenosine SPECT
		Risk Stratification in the Thrombolytic Era
		Risk Stratification with Nuclear Cardiac Imaging in the era of Interventional Cardiology
			Rationale for an Invasive Approach
			Rationale for a Conservative Approach
			Clinical Trial Support for Either Strategy
		The Inspire Trial-Implications for risk Stratification
		Current Guidelines for Stratifying risk in St-Elevation ami
		Current Guidelines for Stratifying risk in Non-St-Elevation ami
		Conclusion
		References
Section 7: Viability
	36 Pathophysiologic Basis of Hibernating Myocardium
		Introduction
		Irreversible Ischemia and the Evolution of Myocardial Infarction
			Evolution of Acute Myocardial Injury
			Residual Coronary Flow Limits Infarction
			Mechanisms of Myocyte Death
		Functional Consequences of Acute Reversible Ischemia
			Stunned Myocardium
			Short-Term Hibernation During Prolonged Moderate Ischemia
		Pathophysiology of Chronic Repetitive Ischemia
			Chronically Stunned Myocardium
			Chronic Hibernating Myocardium
			Metabolic and Energetic Adaptations to Chronic Ischemia
				Myocardial Glucose Uptake
				Oxygen Consumption
				Fatty Acid Metabolism
			Pathologic Remodeling in Hibernating Myocardium
				Myofibrillar Loss and Glycogen Accumulation
				Myocardial Fibrosis, Cell Death, and Myocyte Hypertrophy
				Global Versus Regional Changes
			Molecular Remodeling in Hibernating Myocardium
				Mitochondrial Proteins and Metabolism
				Contractile Proteins and Cellular Calcium Handling
				Cell Survival Program and Antiapoptotic Program in Response to Repetitive Ischemia
				Inhomogeneity in Sympathetic Innervation and beta-Adrenergic Signaling
		Translation of Mechanistic Studies to the Clinical Assessment of Viability
			Blunted Contractile Reserve in Viable Myocardium
			Roles of Myocyte Loss and Cellular Remodeling in Limiting Functional Recovery
			The Impact of Hibernating Myocardium on Prognosis (See Chapters 37 and 38)
		Summary
		References
	37 Assessment of Myocardial Viability with Thallium-201 and Technetium-Based Agents
		Introduction (See Chapter 36)
		Thallium-201 Imaging to Assess Myocardial Viability
			Stress-Redistribution Imaging
			Late Thallium-Redistribution Imaging
			Thallium-Reinjection Techniques
			Rest-Redistribution Thallium Imaging
			Quantitative Analysis of Thallium Data
		Technetium-99m Perfusion Imaging to Assess Viability
			Other Technetium-99m-Based Tracers
		Dual-Isotope Imaging
		Clinical Implications
			Viability Assessment and Patient Outcome
		References
	38 Assessment of Myocardial Viability with Positron Emission Tomography
		Introduction
		Methods for Assessing Myocardial Viability with Pet
			Myocardial Perfusion Tracers
			Fluorine-18-Deoxyglucose (See Chapter 40)
				Physiologic Basis
				Protocols
				Patient Preparation for FDG Imaging
				Myocardial Perfusion and Glucose-Loaded FDG Patterns
				Special Considerations for the Hybrid Myocardial Perfusion SPECT and FDG PET Approach
				Gated FDG Study
				Hybrid FDG Positron Emission Tomography and Computed Tomography
			Carbon-11-Acetate
				Physiologic Basis
				Quantification of Myocardial Carbon-11-Acetate Kinetics (See Chapter 40)
		Accuracy and Impact of Viability Assessment by Pet
		Predicting Improvement in Regional left Ventricular Function
			Myocardial Perfusion
			FDG With and Without Myocardial Perfusion
			Measures of Myocardial Oxidative Metabolism
		Predicting Improvement in Global left Ventricular Function
			Predicting Improvement in Symptoms and Exercise Capacity
			Predicting a Reduction in Hospital Readmissions for Congestive Heart Failure
			Predicting Improvement in Survival
		Relative Value of fdg pet versus Spect in Management Decisions
		Conclusions and Future Directions
		References
	39 Myocardial Viability: Comparison with Other Techniques
		Introduction
		Definition of Myocardial Viability (See Chapter 36)
		Noninvasive Imaging Techniques (See Chapters 37 and 38)
			Echocardiography
				Echocardiography at Rest
				Dobutamine Stress Echocardiography
				Novel Technical Developments in Echocardiography and Viability Assessment
				Echocardiography with Intravenous Contrast
			Magnetic Resonance Imaging
			Additional Information Provided by Echocardiography and MRI
		Comparison of the Different Techniques
		Conclusions
		References
Section 8: Tracer Specific Imaging Techniques
	40 Imaging of Myocardial Metabolism
		Introduction
		Methods to Image Myocardial Metabolism
			Magnetic Resonance Spectroscopy
			Single-Photon Emission Computed Tomography (SPECT) (See Chapter 2)
			Positron Emission Tomography (PET) (See Chapter 3)
				Myocardial Oxygen Consumption (MVO2) (See Chapter 38)
				Carbohydrate Metabolism (See Chapter 38)
				Fatty Acid Metabolism
		Overview of Myocardial Metabolism: Need for Flexibility in Substrate use
			Gender and Aging
			Ischemia
			Hypertension/Left Ventricular Hypertrophy
			Nonischemic Dilated Cardiomyopathy
			Diabetes Mellitus (See Chapters 2 and 29)
			Obesity and Insulin Resistance
		Beyond the Myocardium: Vascular Imaging (See Chapter 44)
		Future Needs
		References
	41 Cardiac Neurotransmission Imaging: Single-Photon Emission Computed Tomography
		Introduction
		Metaiodobenzylguanidine (See Chapter 30)
			Planar and SPECT Cardiac Imaging with 123I-MIBG
			123I-MIBG Imaging in Coronary Artery Disease
			123I-MIBG Imaging in Arrhythmogenesis
			123I-MIBG Imaging in Heart Failure (See Chapter 30)
				Assessment of Prognosis
				Assessment of Treatment
			123I-MIBG Imaging in Heart Transplantation
			123I-MIBG Imaging in Dysautonomias
				Diabetes Mellitus
				Neurodegenerative Disorders
			123I-MIBG Imaging in Drug-Induced Cardiotoxicity
		Conclusions
		References
	42 Cardiac Neurotransmission Imaging: Positron Emission Tomography
		Introduction
		The Cardiac Autonomic Nervous System
			Sympathetic Nerve Terminal
			Parasympathetic Nerve Terminal
		Pet Tracers for Cardiac Neurotramsmitter Imaging
			Carbon-11-Hydroxyephedrine
			Fluorine-18-Fluorodopamine
			Carbon-11-Epinephrine
			Carbon-11-Phenylephrine
			Other Sympathoadrenergic Tracers
			Tracers for Parasympathetic Innervation
		Disease-Related Experimental and Clinical Observations
			Coronary Artery Disease/Myocardial Infarction
			Heart Failure/Cardiomyopathy
			Arrhythmogenic Disorders
			Diabetes Mellitus
			Cardiac Transplantation
			Primary Neurologic Disorders
		Summary and Future Perspective
		References
Section 9: New Molecular Approaches
	43 Molecular Imaging Approaches for Evaluation of Myocardial Pathophysiology: Angiogenesis, Ventricular Remodeling, Inflammation, and Cell Death
		Introduction
		Angiogenesis
		Radiotracer-Based Imaging of Angiogenesis
			Vascular Endothelial Growth Factor Receptors
			Integrin αvbeta3
		Ventricular Remodeling
		Radiotracer-Based Imaging of Left Ventricular Remodeling
			MMPs
			Factor XIII
			ACE Inhibitors and AT1 Antagonists
			Integrin αvbeta3
		Inflammation
		Radiotracer-Based Imaging of Inflammatory-Mediated Processes
			Antimyosin Antibodies
			Antitenascin-C Antibody
			LTB4 Receptor
		Cell Death
			Apoptosis Versus Necrosis
		Radiotracer-Based Imaging in Apoptosis and Necrosis
			Annexin V
			Caspase Inhibitors
			Pyrophosphate and Glucarate
		Conclusions
		References
	44 Radionuclide Imaging of Inflammation in Atheroma
		Introduction
		Evolution of Atherosclerotic Lesions
		Pathogenetic Basis of Inflammation in Atherosclerosis
		Approaches to Imaging Atheroma
		Imaging Inflammation in Coronary Atheroma
		Targeting of Apoptosis in Atheroma
		Future of Atherosclerosis Imaging
		References
	45 Molecular Imaging of Gene Expression and Cell Therapy
		Introduction
		Fundamentals of Gene Expression
		Background of Cardiovascular Molecular Imaging
		Imaging Techniques
			Optical Imaging
			Magnetic Resonance Imaging
			Ultrasound
			Computed Tomography
			Radionuclide Imaging (See Chapter 11)
		Imaging Cardiac Gene Therapy
		Imaging Cardiac Cell Delivery
			Radionuclide Labeling
			Nanoparticle Labeling
			Iron Particle Labeling
			Reporter Gene Labeling
			Clinical Imaging
		Conclusion
		References
Case 1
	Baseline ECG
	Exercise Parameters
	Peak Exercise ECG
	Raw Planar Images
	Short-Axis Tomograms
	SPECT Tomographic Slices
	Polar Map
	Quantitative Polar Map
	Gated SPECT Images
	Patient Management
	Coronary Angiography
	Detection of Left Main Stenosis
Case 2
	National Cholesterol Education Program (NCEP) Adult Treatment Panel III
	Framingham Risk Score
	NCEP Adult Treatment Panel III
	Proposed Management Strategy for Asymptomatic Patients
	Coronary Calcium Score
	Clinical Questions
	Proposed Management Strategy for Asymptomatic Patients
	Exercise SPECT MPI
	Duke Treadmill Score
	SPECT Images
	Gated SPECT Images
	ASNC Management Strategy for Asymptomatic Patients
	Recommendations
	Coronary Angiography
	Teaching Points (See Chapters 20 and 22)
Case 3
	Exercise Data
	SPECT Images
	Clinical Questions
	Framingham Risk Score
	Coronary Calcium Score (CCS)
	Patient Management
Case 4
	Baseline 12-Lead ECG
	Raw Planar Images
	SPECT Tomographic Slices
	Polar Maps
	Coronary Angiography
Case 5
	Raw Planar Images and SPECT Tomograms
	Quantitative Polar Map
	Gated SPECT Images
	PET Tomograms
	Gated PET Images
Case 6
	Raw Images
	SPECT Tomograms
	Quantitative Polar Map
	Gated SPECT Images
	PET Tomograms
	Gated PET Images
	Coronary Angiography
Case 7
	Initial Diagnostic Evaluation
	Baseline ECG
	4:50 Adenosine (Mild Chest Pain)
	5:50 Recovery (Persistent Chest Pain)
	9:00 Recovery (Worsening Chest Pain)
	14:50 Recovery (No Chest Pain)
	Rotating Raw Planar Images
	SPECT Images
	Gated SPECT Images
	Patient Management
	Coronary Angiography
	Coronary Angiography
	Teaching Points: Stress-Induced ST-Segment Elevation
Case 8
	SPECT Images
	Defect Severity Polar Maps
	Gated SPECT Images
	Echocardiography
	Echocardiogram-SPECT Correlation
	Teaching Points: MPI in Hypertrophic Cardiomyopathy
Case 9
	SPECT Images
	Polar Map
	Viability Polar Map
	Poststress Gated SPECT Images
	Coronary Angiography
	Myocardial Stunning or Imaging Artifact?
	Clinical Follow-Up
	SPECT Images 8 Months Later
	Gated SPECT Images 8 Months Later
	Comparison of Resting SPECT Images at Baseline and 8 Months After PCI
	Teaching Point
Case 10
	Short-Axis SPECT Images
	Rotating Raw Planar Images
	Teaching Points: \"Shifting\" Breast Attenuation (See Chapter 5)
Case 11
	Baseline ECG
	Echocardiogram
	Raw Planar Images
	SPECT Images
	Polar Maps
	Gated SPECT Images
	Teaching Points
		SPECT MPI in Cardiomyopathy (See Chapter 30)
Case 12
	Raw Planar Images
	SPECT Images
	Quantitative Polar Maps
	Gated SPECT Images
	Teaching Points: Left Mastectomy
	Quantitative Polar Maps
	Quality-Control Display
	Dipyridamole Stress PET Images
	Gated PET Images
Case 13
	12-Lead ECG
	PET Images
	Quantitative Polar Map
	Gated PET Images
	Coronary Angiography
	Cardiac Catheterization
	Coronary Angiography
	Teaching Points: Detection of Balanced Ischemia
Case 14
	12-Lead ECG
	Functional (Gated) CT Left Ventricular Angiogram
	Coronary Calcium Score (CCS)
	Coronary CTA of Left Main
	Coronary CTA of Left Anterior Descending
	Coronary CTA of Left Circumflex
	Proximal Right Coronary Artery
	Mid-RCA
	Coronary CTA of Right Coronary Artery
	Clinical Questions
	Complementary Roles of MPI and CTA (See Chapter 22)
Case 15
	12-Lead ECG
	Perfusion and Glucose Metabolism
	Semiquantitative Assessment of Myocardial Perfusion and Glucose Metabolism
	Peak stress Perfusion and Glucose Metabolism
	Resting Perfusion and Glucose Metabolism
	Peak stress and Resting Gated PET Images
	Practical Approach to Assessment of Myocardial Viability (See Chapters 37 and 38)
	An Example in Which 18FDG Imaging Adds Important Incremental Information to the Assessment of Myocardial Viability...
Case 16
	Further Reading
Case 17
	Further Reading
Case 18
	Further Reading
Case 19
Case 20
	Discussion
	Further Reading
Case 21
	Further Reading
Case 22
	Acknowledgment
	Further Reading
Case 23
	Further Reading
Case 24
Case 25
	Further Reading
Case 26
Case 27
Case 28
Case 29
Case 30
Case 31
	Further Reading
Case 32
Case 33
Case 34
Case 35
Index
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	D
	E
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	Q
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	T
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