Pharmacologic Radionuclide Perfusion Stress Test

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CAD (class I and IIa indications—evidence clearly demonstrates benefit, and evidence appears to favor benefit, respectively):

  • To evaluate for coronary disease in patients with symptoms unable to exercise adequately on a treadmill or in whom resting ECG shows LBBB
  • To identify the extent, severity, and location of ischemia in patients with LBBB or paced rhythm, or who have ECG abnormalities that interfere with interpretation of exercise-induced ST segment changes
  • To assess the functional significance of intermediate coronary lesions
  • To re-stratify risk by repeated imaging in a patient with CAD whose symptoms have changed
  • To assess myocardial risk in patients with possible acute coronary syndrome with nondiagnostic ECG and initial serum markers/enzymes and a normal resting scan
  • To assess therapy after thrombolytic therapy for acute STEMI to detect inducible ischemia and assess infarct size
  • To assess location and severity of inducible ischemia after NSTEMI in patients whose angina is stabilized on medical therapy
  • For risk stratification in patients without symptoms 3 to 5 years after revascularization (PCI or CABG)
  • As an initial test in patients at high risk (diabetes, or otherwise defined as having a >20% 10-year risk of coronary event)
  • For evaluation before noncardiac surgery
    • Initial diagnosis of CAD in patients with intermediate pretest probability of disease and abnormal baseline ECG
    • Prognostic assessment of patients with suspected or proved CAD
    • Evaluation of patients after change in clinical status (e.g., acute coronary syndrome)
    • Assessment of patients with intermediate clinical risk, abnormal ECG, and high-risk surgery


  • STEMI (within 2 weeks); NSTEMI (within 72 hours)
  • High-risk unstable angina; ongoing chest pain, chest pain within the last 12 hours associated with ST elevation or new ST depression, or ongoing requirement of IV nitroglycerin infusion
  • Uncontrolled arrhythmias
  • Symptomatic severe aortic stenosis: AVA <1.0 cm2 or peak gradient of >70 mm Hg
  • Decompensated heart failure
  • Acute pulmonary embolus or pulmonary infarction
  • Acute myocarditis or pericarditis
  • Acute aortic dissection
  • Severe hypertension (SBP >180 mm Hg or <90 mm Hg; DBP >110 mm Hg) or hypotension (SBP <90 mm Hg)
  • Caffeine or xanthine-containing medications or products ingested within 24 hours of the study; 12 hours if using regadenoson
  • Baseline ECG demonstrated first-degree AVB >260 msec in combination with widened QRS (unless pacemaker present)
  • Second- or third-degree AVB (unless pacemaker present)
  • History of asthma, RAD, or significant wheezing noted on the day of the stress study


  • Known significant left main coronary stenosis.
  • Electrolyte abnormalities.
  • Hypertropic cardiomyopathy and other forms of outflow tract obstructions.
  • Patients are required in many scanners to lie with their arms over their head for the period of scanning—those unable to do so (due to musculoskeletal issues) cannot be scanned, and alternative imaging should be considered.
  • Morbid obesity may preclude patient being able to fit into scanner, and alternative imaging should be considered.
  • Pregnancy and/or breastfeeding.
  • ECG machine and monitor
  • Gamma imaging camera
  • Portable BP cuff and stethoscope
  • IV infusion pump
  • Equipment for IV catheterization
    • 20-gauge IV catheter
    • Tourniquet
    • Alcohol swab
    • Local anesthetic and 3-mL syringe with small (25- or 30-gauge) needle for subcutaneous infiltration of local anesthetic
    • Tape
  • Radiotracer doses (weight adjusted); one each for rest and stress (e.g., 99mTc)
  • Crash cart with resuscitation equipment, resuscitation drugs, defibrillator, and pacing capacity
  • Oxygen source and delivery system (nasal cannula, face mask)
  • Two doses of radiotracer (rest and stress) prepared for injection
  • Injectable vasodilator (adenosine 140 mcg/kg/min infused over a 5-minute period, dipyridamole 0.57 mg/kg infused over a 4-minute period, or regadenoson standard 0.4-mg bolus injection)
  • IV aminophylline, up to 225 mg
  • Bandage or gauze for IV site after the procedure

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  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
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  • The patient should be observed until vital signs have returned to baseline, patient is without symptoms, and ECG changes, if any, have resolved.
  • Discontinue the IV if one is present, and apply bandage.
  • Answer any questions for the patient, and arrange follow-up plans.
  • Supervising provider completes reporting and finalizes report.
  • Vasovagal reaction to IV start (if an IV is used).
  • Possible reaction to tracer or carrier fluid with IV injection, very rare.
  • Hemodynamic effects of vasodilator administration.
    • Average drop of 8 to 10 mm Hg in SBP and DBP.
    • Reflex tachycardia may result from BP drop.
  • Common side effects (in 50%) flushing, chest pain, or shortness of breath.
  • AVB can occur, with first-degree block in 10% and either second- or third-degree block in 5%.
  • Ischemia (manifested as ST-segment changes) occurs in 10% to 15% of patients.
  • Chest pain, including typical angina, is a common and nonspecific finding.
  • Bronchospasm is infrequent but can be severe and life-threatening.

Key elements in analysis and reporting are the extent of ischemia, extent of infarct, and localization to specific myocardial regions. Specifically:

  • Presence of perfusion defects
  • Location of perfusion defects
  • Type of defect
    • Irreversible (implying myocardial infarction) or
    • Reversible at rest (implying stress-induced ischemia)
  • Common image artifacts include the following:
    • Lung uptake of tracer during stress; often an indication of severe CAD, perhaps due to elevation of capillary wedge pressure during exercise
    • Breast attenuation
    • Inferior wall attenuation; may be caused by extracardiac structures, such as the diaphragm
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