Patient Preparation

Dynamic exercise

Dynamic exercise is the stress technique of choice in patients with suspected or known CAD, provided that the patient is able to exercise at an acceptable workload (≤85% of the maximum predicted heart rate).^{[41, 42]}

The patient should withdraw from drugs that may interfere with a physiologic exercise response. Beta antagonists and calcium channel antagonists should be discontinued for 5 half-lives before the test unless medically contraindicated. Patients should avoid caffeine-containing foods, beverages, and drugs for a minimum of 12 hours before the test. This allows the use of vasodilator agents in cases where the exercise is terminated and pharmacologic stress is undertaken. Patients should be instructed to dress appropriately for exercise. Fasting is not essential. Although many centers routinely fast patients before imaging, the advantages of this policy is unproven.

Pharmacologic stress

Pharmacologic stress is an excellent alternative to dynamic exercise. Pharmacologic stress with vasodilators is the procedure of choice for patients unable to exercise adequately^[43]or for those with LBBB or paced rhythm.^[44]

Patients stressed with the vasodilators adenosine or dipyridamole (vasodilator stress) must abstain from caffeinated foods, beverages, and drugs for a minimum of 12 hours before the test and preferably for 24 hours.^[45]Aminophylline and theophylline must be stopped 24 hours before the test.^[46]Patients on dipyridamole should discontinue the drug for a minimum of 24 hours before vasodilator stress.

Patients stressed with dobutamine should stop beta antagonists for 5 half-lives or at least 24 hours before the test unless contraindicated.

No anesthesia is required before SPECT testing.

Positioning

The patient should be supine with both arms above the head, as shown below.

Positioning. The patient should be supine with both arms above the head. Courtesy of Philips Healthcare.

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Knee support may also be helpful because patient’s comfort is essential to minimize motion. Prone imaging has been used in some centers to reduce the incidence of inferior attenuation artifact^[47]but can produce anterior artifacts and is not recommended in isolation.

Female patients should be imaged without underwear. A chest band can be used to minimize breast attenuation and to ensure reproducible positioning during later image acquisition.

Technique

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Media Gallery

Device summary. To acquire single-photon emission computed tomography (SPECT) images, the patient lies still in a supine position, and the gamma camera is rotated around the patient. Courtesy of Patrick J. Lynch, Yale University.
Single-photon emission computed tomography (SPECT) images compared with illustrations of the heart from similar views. The SPECT images (bottom row) show the distribution of the tracer and therefore the relative blood flow to the different regions of the myocardium. The top rows are illustrations of the heart to compare with the SPECT images from similar views. Notice there are more enhancements in the area that corresponds to the left ventricle because of its greater thickness. Courtesy of Patrick J. Lynch, Yale University.
Planar imaging. The gamma camera detects the gamma rays emitted from the tracer, and the image of where the tracer is found in the organs is transmitted to the computer. In planar technique, the computer provides a 2-dimensional myocardial perfusion image. Courtesy of Patrick J. Lynch, Yale University.
SPECT imaging performed after stress. The upper row shows short-axis slices after pharmacologic stress; the lower row shows the same slices when the body is at rest in conventional cardiac SPECT with Tc-99m tetrofosmin as a radiotracer. Arrows indicate a small perfusion defect on the backside of the heart (visible only on the stress images), showing ischemia in this region of the heart wall. Courtesy of Philipp A Kaufmann, MD, and Oliver Gämperli, MD, University Hospital Zurich.
Positioning. The patient should be supine with both arms above the head. Courtesy of Philips Healthcare.