NC Core Curriculum

Welcome to the Nuclear Cardiology Core Curriculum webpage. ASNC is committed to providing educational resources to our members at every level of training. Nuclear Cardiology utilizes highly technical imaging systems combined with sophisticated image processing algorithms to generate studies that provide essential diagnostic and prognostic information that can be used to optimize patient care. It is therefore essential that healthcare professionals involved in the performance of stress testing, image acquisition, and image interpretation understand the fundamentals on which those are based. The modules on this page provide important foundational information on these aspects of nuclear cardiology upon which Fellows-in-Training can build their understanding of the application of these techniques in patient management.ASNC Past President Raymond Russell, III, MD, PhD, MASNC

NC Core Curriculum Lectures

This activity is based on the live Fellows-in-Training program presented in 2018, the goal is to provide a better understanding of the role of nuclear cardiology in evaluating patients with a variety of cardiac conditions to ensure appropriate use is in place when using nuclear cardiology diagnostic imaging. It provides a prospective on the complementary as well as alternate role of other imaging modalities in the evaluation of patients with heart disease and review existing nuclear cardiology protocols. Lectures expand on the appropriate use criteria and implementation of nuclear cardiology imaging and its role among the multiple imaging methods available to assess cardiac perfusion.  The program features leading experts in nuclear cardiology.

 Core Curriculum Sessions from
the ASNC2017 Scientific Session

How does radionuclide imaging guide clinical decision making?
  • How to decide when to proceed to angiography
  • Prepoperative testing: When is preopoerative evaluation helpful?
Nuclear cardiology can play a vital role in diagnosing and guiding therapy for ischemic heart disease. In this module, the application and appropriate use of myocardial perfusion imaging and viability assessment are discussed in the context of three clinical scenarios: detection of ischemic heart disease, assessment of myocardial viability, and preoperative cardiac risk stratification.

Evaluation of suspected coronary artery disease in women
  • Challenges in the evaluation of heart disease in women
  • In women, anatomic imaging with CT is preferred
One of the important challenges in medicine is to correct the underdiagnosis of coronary artery disease in women. This module focuses on the challenges in diagnosing coronary artery disease in women and identifying the most appropriate diagnostic strategies to detect heart disease in women.

Patients are different-So are protocols
  • BMI-based dosing
  • Stress first or rest first?
  • Pharmacologic stress agents-Which is the best for my patient?
The right test for the right patient. This module provides useful information to optimize the study to answer the clinical question, including selecting the best stress protocol, weight-based radiotracer dosing, and stress-only imaging.

Not just pushing buttons
  • Acquisition parpmeters (conventional and solid state)
  • Processing parameters (conventional and resolution recovery)
  • Types of filters and their parameters
Understanding the principles of image acquisition and processing is essential to providing high-quality nuclear cardiac studies. In this module, the physics behind traditional and solid state cameras as well as image processing and filters are explained.

JNC Articles

Sabahat Bokhari, MD, Reehan Shahzad, MD, Adam Castano, MD, Mathew Maurer, MD
J Nucl Cardiol. 2014;21:175-184.

Cardiac amyloidosis is often challenging to diagnose and is almost always associated with a poor prognosis and is an underdiagnosed cause of heart failure with preserved ejection fraction. It involves deposits of monoclonal light chain (AL) or transthyretin (ATTR, mutant or wild-type ) types in the majority of cases. With the emergence of subtype-specific treatments, nuclear imaging plays an important role in identifying myocardial involvement and differentiating amyloid subtypes. In this article, Dr. Bokhari and colleagues review the role nuclear imaging in detection of cardiac amyloid.
  Steven J. Promislow, MD, Terrence D. Ruddy, MD
J Nucl Cardiol. 2018 May 18. doi: 10.1007/s12350-018-1295-7. [Epub ahead of print]

With the improvements in treatments for light chain amyloidosis and promising new treatments option for transthyretin amyloid, there is a need for early and accurate diagnosis of cardiac amyloidosis and distinguishing between the two common subtypes. This recent editorial comments on a small study using of 11C-PIB (Pittsburgh compound B) to identify a subset of patients with cardiac amyloid who have a poor prognosis. The editorial discusses the use of 11C-PIB and it limitations and points out, that in the future ,other PET tracers may offer prognostic data, as well monitor disease progression in patients with cardiac amyloidosis.
  Aiden Abidov, MD, PhD, Guido Germano, PhD, Rory Hachamovitch, MD, MSc, Daniel S. Berman, MD
J Nucl Cardiol. 2006;13:261-79. – 2006

In this Major Achievements in Nuclear Cardiology article, Abidov and colleagues discuss the use of ECG–gated SPECT and the ability to measure left ventricular ejection fraction(LVEF) and ventricular volumes, as well as evaluate the presence of regional wall motion abnormalities (RWMAs), as a routine part of clinical protocols. The 2003 ACC/AHA/ASNC  guidelines for the clinical use of cardiac radionuclide imaging considered ECG-gated SPECT as the “current state of the art” citing the ability to observe myocardial contraction in segments with apparent ?xed perfusion defects permits the nuclear test reader to discern attenuation artifacts from true perfusion abnormalities increasing diagnostic accuracy. In addition, the ability of gated SPECT to provide measurement of LVEF, segmental wall motion, and absolute LV volumes adds to the prognostic information derived from a SPECT study. The authors review the technical milestones, acquisition algorithms, analysis and added value gated-SPECT brings to the diagnostic and prognostic information available from myocardial perfusion imaging. 
  Aiden Abidov, MD, PhD, Guido Germano, PhD, Rory Hachamovitch, MD, MSc, Piotr Slomka, PhD, Daniel Berman, MD
J Nucl Cardiol. 2013;20:1118-1143.

Gated myocardial SPECT is a routine part of myocardial perfusion imaging protocols.  It can be used to obtain quantitative information about myocardial perfusion, thickness, and contractility including  calculations of left ventricular ejection fraction, stroke volume, and cardiac output. In this ASNC 20th anniversary article, Abidov and colleagues review the development, technical advancements, and clinical utility of gated myocardial perfusion SPECT imaging.
  Kenneth A. Brown, MD
J Nucl Cardiol. 1996;3:516-537.

Dr. Brown was a leader in establishing the prognostic value of myocardial perfusion imaging. In 1983 in JACC, Brown and colleagues published an article describing the value of exercise thallium-201 imaging in patients presenting for evaluation of chest pain to predict future cardiac events (cardiovascular death or nonfatal myocardial infarction). Data was correlated with clinical, coronary and left ventricular angiographic and exercise electrocardiographic information.  Much has been published regarding the prognostic value of myocardial perfusion imaging since that first article, but this 1996 review provides the fundamentals of how this information has shaped nuclear cardiology today. 
  Kenneth A. Brown, MD
J Nucl Cardiol. 2004;11:335-48.

Nuclear imaging is an important component for assessing cardiac risk and guiding therapy in patients scheduled for noncardiac surgery.  Much has changed with surgical techniques and understanding the role of preoperative risk assessment has evolved.  Appropriate use criteria are available to help clinicians refer the right patients for testing prior to surgery. This 2004 Achievements in Nuclear Cardiology describes nuclear imaging at that time and emphasizes the importance of taking into account clinical predictors, functional capacity, and the type/risk of noncardiac surgery prior to testing, similar to current recommendations.
  Robert C. Hendel, MD, Tariq Jamil, MD, David K. Glover, ME
J Nucl Cardiol 2003;10:197-204.

In this 2003 review, current experience with available stress agents and imaging protocols are described. The ability to perform pharmacologic stress myocardial perfusion imaging has extended stress testing to patients unable to perform maximal exercise. Protocols have evolved and regadenoson is now available for clinical use, but this review provides information on how the field has advanced and contributed to the growth of nuclear cardiology.  Today, more than 50% of myocardial perfusion imaging studies are performed using pharmacologic stress helping to appropriately and effectively manage patients with known or suspected coronary disease who cannot adequately exercise.  
  Dalia Y. Ibrahim, MD, Frank P. DiFilippo, PhD, Jeremy E. Steed, BS, CNMT, and Manuel D. Cerqueira, MD
J Nucl Cardiol 2006;13:855-66.

Single photon emission computed tomography (SPECT) myocardial perfusion imaging is the work horse of nuclear cardiology but it is not without limitations.  Image artifacts resulting from unique features of the patient’s body and behavior during the acquisition, the distribution of the radiopharmaceuticals outside of the heart, and technical factors associated with image acquisition, processing, and display can impact specificity. This review focuses on the practical problems encountered with SPECT imaging over a decade ago and the methods used to overcome them.  Technology has undergone significant evolution since this review was published, but many of the issues identified impact imaging today and need to be addressed  to obtain optimal SPECT images and to achieve an accurate diagnosis.
  Michael I. Miyamoto, MD, MS, Haresh Majmundar, BS, CNMT,  Sharon L. Vernotico, RN, Gregory S. Thomas, MD, MPH
J Nucl Cardiol 2007;14:250-255.

This 2007 Practical Points in Nuclear Cardiology discusses a practical approach to the use of adenosine as a vasodilator stress agent. Patient selection, scheduling, preparation, imaging protocol, study interpretation and reporting are discussed. The potential advantages of regadenoson over adenosine are also described.  Recent ASNC Practice Points provide important information on the use adenosine, dobutamine, dipyridamole and regadenoson for pharmacologic stress testing.