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## Complete Summary

#### GUIDELINE TITLE

ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide
imaging: A report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines (ACC/AHA/ASNC Committee to
revise the 1995 guidelines for the clinical use of cardiac radionuclide
imaging).

#### BIBLIOGRAPHIC SOURCE(S)

ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide
imaging: a report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines (ACC/AHA/ASNC Committee to
revise the 1995 guidelines \[trunc\]. Bethesda (MD): American College of
Cardiology Foundation; 2003. 69 p. \[519 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Ritchie JL, Bateman TM, Bonow
RO, Crawford MH, Gibbons RJ, Hall RJ, O\'Rourke RA, Parisi AF, Verani
MS. Guidelines for clinical use of cardiac radionuclide imaging. Report
of the American College of Cardiology/American Heart Association Task
Force on Assessment of Diagnostic and Therapeutic Cardiovascular
Procedures (Committee on Radionuclide Imaging), J Am Coll Cardiol 1995
Feb;25(2):521-47.

These guidelines will be reviewed 1 year after publication and yearly
thereafter and considered current unless the Task Force on Practice
Guidelines revises or withdraws them from circulation.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Chest pain

-   Acute myocardial infarction (AMI)

-   ST-elevation acute myocardial infarction(STEMI)

-   Non-ST-elevation acute myocardial infarction (NSTEMI)

-   Unstable angina (UA)

-   Coronary artery disease (CAD)

-   Heart failure

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Diagnosis\
Risk Assessment

#### CLINICAL SPECIALTY

Cardiology\
Critical Care\
Internal Medicine\
Nuclear Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To make recommendations regarding the appropriate use of cardiac
radionuclide imaging in the diagnosis and treatment of patients with
known or suspected cardiovascular disease

#### TARGET POPULATION

Adults with known or suspected cardiovascular disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Myocardial perfusion imaging (MPI)

    -   Stress imaging through:

        -   Exercise (treadmill or upright or supine bicycle)

        -   Pharmacologic modalities

            -   Vasodilators (dipyridamole and adenosine)

            -   Dobutamine

    -   Consider concomitant use of drugs (e.g., beta-adrenergic agents,
        calcium channel blockers, nitrates, caffeine)

    -   Perfusion tracers:

        -   Thallium-201

        -   Tc-99m-sestamibi

        -   Tc-99m-tetrofosmin

        -   Tc-99m-teboroxime (approved for use but not currently
            marketed in the United States)

        -   Note: Tc-99-m-NOET is currently undergoing multicenter
            trials and is not yet approved for use.

    -   Dual-isotope MPI

    -   Gated-planar MPI

    -   Gated-single-photon emission computed tomography (SPECT) MPI

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2.  Analysis of ventricular function

    -   Radionuclide angiography (RNA)

        -   First-pass RNA (FPRNA) (Rest, stress)

        -   Planar and SPECT-gated equilibrium blood pool RNA (Rest,
            stress)

    -   Procedures for determination of ejection fraction and volumes:

        -   FPRNA

        -   Gated-equilibrium blood pool RNA

        -   Gated-SPECT perfusion imaging

3.  Myocardial infarct-avid imaging

4.  Myocardial ischemia imaging

5.  Positron emission tomography

#### MAJOR OUTCOMES CONSIDERED

-   The clinical utility of nuclear cardiological techniques in the
    diagnosis, assessment of disease severity/risk assessment/prognosis,
    and assessment of therapy in patients with cardiovascular disease

-   The sensitivity, specificity, accuracy, cost-effectiveness, and
    effect of positive or negative results from nuclear cardiological
    techniques on subsequent clinical decision making

-   Morbidity and mortality due to cardiovascular disease

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline committee conducted comprehensive searching of the
scientific and medical literature on radionuclide imaging in heart
disease. Because the guideline represents a full revision, no time
constraints were applied to the searches and all relevant references
were reviewed. In addition to broad based searching on radionuclide
imaging, specific targeted searches were performed on radionuclide
imaging and the following subtopics: chest pain, viability, ejection
fraction (EF), hypertensive heart failure, hypertrophic heart failure,
electron-beam computed tomography (EBCT), adenosine, technetium-99m
(Tc-99m), antimyosin, dipyridamole, glucarate, risk stratification,
prognosis, non-Q-wave infarction, gamma-camera imaging, positron
emission tomography (PET), acute myocardial infarction (AMI), heart
failure, ischemia, ventricular volumes, left ventricular (LV) function,
and angina. The committee reviewed all compiled reports from
computerized searches and conducted additional hand searching.
Throughout this literature review, abstracts of unpublished data more
than 2 years old were excluded.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

A.  Data derived from multiple randomized clinical trials

B.  Data derived from a single randomized trial, or from nonrandomized
    studies

C.  Consensus opinion of experts

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Guidelines for the Clinical Use of Cardiac Radionuclide Imaging were
originally published in 1986 and updated in 1995. Important new
developments have continued to occur since 1995, particularly in the
areas of acute and chronic ischemic syndromes and heart failure. The
Task Force therefore believed the topic should be revisited de novo and
invited the American Society for Nuclear Cardiology (ASNC) to cosponsor
this undertaking. This report represents a joint effort of the three
organizations. The committee that prepared it included acknowledged
experts in radionuclide testing, as well as general cardiologists and
cardiologists with expertise in other imaging modalities. Committee
members were drawn from both the academic and private practice sectors,
with the three sponsoring organizations equally represented.

Writing groups were specifically charged to perform a formal literature
review, weigh the strength of evidence for or against a particular
treatment or procedure, and include estimates of expected health
outcomes when data exist. Patient specific modifiers, comorbidities, and
issues of patient preference that might influence the choice of
particular tests or therapies were considered, as well as frequency of
follow-up and cost effectiveness.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The American College of Cardiology/American Heart Association
classifications I, II, and III are used to summarize indications as
follows:

**Class I**: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and effective

**Class II**: Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness/efficacy of a procedure or
treatment

**Class IIa**: Weight of evidence/opinion is in favor of
usefulness/efficacy

**Class IIb**: Usefulness/efficacy is less well established by
evidence/opinion

**Class III**: Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful/effective and in
some cases may be harmful

#### COST ANALYSIS

The American College of Cardiology/American Heart Association (ACC/AHA)
2002 Guideline Update for the Management of Patients With Chronic Stable
Angina encourages the use of cardiac imaging as a gatekeeper to cardiac
catheterization in order to minimize the rate of normal catheterizations
and to enrich the angiographic population with a greater proportion of
patients with significant, yet treatable disease. To test the principle
of selective resource use, a team of researchers reported that when
catheterization was limited to patients with moderate-severe perfusion
abnormalities (i.e., summed stress score \[SSS\] greater than 8),
significant cost savings were achieved for 5,183 patients undergoing
dual isotope stress single-photon emission computed tomography (SPECT)
imaging. The results revealed a 17% reduction in the rate of cardiac
catheterization and cost savings ranging from 22 to 55% for high- to
low-risk pretest patients. The SSS appeared to identify patients who
benefited from revascularization; in comparing the patients undergoing
early revascularization to those undergoing medical therapy, a reduction
in mortality with revascularization was observed only in those with very
abnormal SSS. Another team of researchers have reported similar
excellent outcomes with medical versus invasive strategies in patients
without high-risk stress nuclear findings.

A third group evaluated a population of 11,249 consecutive stable angina
(SA) patients, gathered in a large multicenter trial comprising many
U.S. laboratories. In a matched cohort study comparing direct
catheterization to myocardial perfusion SPECT with selective
catheterization in patients with chronic stable angina, for all levels
of pretest clinical risk, there was a substantial reduction (31 to 50%)
in costs when using the SPECT plus selective catheterization approach.
This reduction was seen in both the diagnostic (early) and follow-up
(late) costs, and included costs of revascularization. Rates of
subsequent nonfatal MI and cardiac death were virtually identical in all
patient risk subsets. The rate of revascularization, however, was
reduced by nearly 50% in the myocardial perfusion imaging (MPI) with
selective catheterization cohort.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This document was reviewed by three official reviewers nominated by the
American College of Cardiology Foundation (ACCF), three official
reviewers nominated by the American Heart Association (AHA), three
official reviewers nominated by the American Society of Nuclear
Cardiology (ASNC), the ACC/AHA Task Force on Practice Guidelines, and
four additional content reviewers.

The document was approved by the American College of Cardiology
Foundation Board of Trustees in July 2003, the American Heart
Association Science Advisory and Coordinating Committee in July 2003,
and the American Society of Nuclear Cardiology Board of Directors in
July 2003.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the weight of the evidence (A-C) and classes of
recommendations (I-III) can be found at the end of the \"Major
Recommendations\" field.

Abbreviations: ACS, acute coronary syndrome; CABG, coronary artery
bypass graft surgery; CAD, coronary artery disease; CCS, coronary
calcium score; CT, computed tomography; ECG, electrocardiogram; FDG,
flurodeoxyglucose; FPRNA, first pass radionuclide angiography; LBBB,
left bundle-branch block; LV, left ventricular or left ventricle; LVH,
left ventricular hypertrophy; MPHR, maximal-predicted heart rate; MPI,
myocardial perfusion imaging; PCI, percutaneous coronary intervention;
PET, positron emission tomography; RNA, radionuclide angiogram; RV,
right ventricular or right ventricle; SPECT, single-photon emission
computed tomography; STEMI, ST-segment elevation myocardial infarction;
Tc-99m, technetium-99m; Tl-201, thallium-201

**Recommendations for Emergency Department Imaging for Suspected Acute
Coronary Syndromes (ACS)**

  ---------------------------------------------------------------------------------
  **Indication**                           **Test**        **Class**   **Level of
                                                                       Evidence**
  ---------------------------------------- --------------- ----------- ------------
  1\. Assessment of myocardial risk in     Rest MPI        I           A
  possible ACS patients with nondiagnostic                             
  ECG and initial serum markers and                                    
  enzymes, if available.                                               

  2\. Diagnosis of CAD in possible ACS     Same day        I           B
  patients with chest pain with            rest/stress                 
  nondiagnostic ECG and negative serum     perfusion                   
  markers and enzymes or normal resting    imaging                     
  scan.                                                                

  3\. Routine imaging of patients with     Rest MPI        III         C
  myocardial ischemia/necrosis already                                 
  documented clinically, by ECG and/or                                 
  serum markers or enzymes                                             
  ---------------------------------------------------------------------------------

Abbreviations: ACS, acute coronary syndromes; CAD, coronary artery
disease; ECG, electrocardiogram; MPI, myocardial perfusion imaging

**Recommendations for Use of Radionuclide Testing in Diagnosis, Risk
Assessment, Prognosis, and Assessment of Therapy After Acute ST-Segment
Elevation Myocardial Infarction (STEMI)**

  ---------------------------------------------------------------------------------
  **Patient         **Indication**           **Test**      **Class**   **Level of
  Subgroup(s)**                                                        Evidence**
  ----------------- ------------------------ ------------- ----------- ------------
  All               1\. Rest LV function     Rest RNA or   I           B
                                             EGC-gated                 
                                             SPECT                     

  Thrombolytic      2\. Detection of         Stress MPI    I           B
  therapy without   inducible ischemia and   with                      
  catheterization   myocardium at risk       ECG-gated                 
                                             SPECT                     
                                             whenever                  
                                             possible                  

  Acute STEMI       3\. Assessment of        MPI at rest   I           B
                    infarct size and         or with                   
                    residual viable          stress using              
                    myocardium               gated SPECT               

                    4\. Assessment of RV     Equilibrium   IIa         B
                    function with suspected  or FPRNA                  
                    RV infarction                                      
  ---------------------------------------------------------------------------------

Abbreviations: ECG, electrocardiography; FPRNA, first-pass radionuclide
angiography; LV, left ventricular; MPI, myocardial perfusion imaging;
RNA, radionuclide angiography; RV, right ventricular; SPECT,
single-photon emission computed tomography; STEMI, ST-segment elevation
myocardial infarction

**Recommendations for Use of Radionuclide Testing for Risk
Assessment/Prognosis in Patients With Non-ST-Segment Elevation
Myocardial Infarction (NSTEMI) and Unstable Angina (UA)**

  --------------------------------------------------------------------------------
  **Indication**                     **Test**             **Class**   **Level of
                                                                      Evidence**
  ---------------------------------- -------------------- ----------- ------------
  1\. Identification of inducible    Stress MPI with ECG  I           B
  ischemia in the distribution of    gating whenever                  
  the \"culprit lesion\" or in       possible                         
  remote areas in patients at                                         
  intermediate or low risk for major                                  
  adverse cardiac events.                                             

  2\. Identification of the          Stress MPI with ECG  I           A
  severity/extent of inducible       gating whenever                  
  ischemia in patients whose angina  possible                         
  is satisfactorily stabilized with                                   
  medical therapy or in whom                                          
  diagnosis is uncertain.                                             

  3\. Identification of hemodynamic  Stress MPI           I           B
  significance of coronary stenosis                                   
  after coronary arteriography.                                       

  4\. Measurement of baseline LV     RNA or gated SPECT   I           B
  function.                                                           

  5\. Identification of the          Rest MPI             IIa         B
  severity/extent of disease in                                       
  patients with ongoing suspected                                     
  ischemia symptoms when ECG changes                                  
  are nondiagnostic.                                                  
  --------------------------------------------------------------------------------

Abbreviations: ECG, electrocardiography; LV, left ventricular; MPI,
myocardial perfusion imaging; RNA, radionuclide angiography; SPECT,
single-photon emission computed tomography

**Cardiac Stress Myocardial Perfusion Single-Photon Emission Computed
Tomography (SPECT) in Patients Able to Exercise**

**Recommendations for Diagnosis of Patients With an Intermediate
Likelihood of Coronary Artery Disease (CAD) and/or Risk Stratification
of Patients With an Intermediate or High Likelihood of CAD Who Are Able
to Exercise (to at least 85% of Maximal Predicted Heart Rate)**

**Class I**

1.  Exercise myocardial perfusion SPECT to identify the extent,
    severity, and location of ischemia in patients who do not have left
    bundle-branch block (LBBB) or an electronically-paced ventricular
    rhythm but do have a baseline electrocardiogram (ECG) abnormality
    that interferes with the interpretation of exercise-induced
    ST-segment changes (ventricular pre-excitation, left ventricular
    hypertrophy \[LVH\], digoxin therapy, or more than 1-mm ST
    depression) (Level of Evidence: B)

2.  Adenosine or dipyridamole myocardial perfusion SPECT in patients
    with LBBB or electronically-paced ventricular rhythm (Level of
    Evidence: B)

3.  Exercise myocardial perfusion SPECT to assess the functional
    significance of intermediate (25 to 75%) coronary lesions (Level of
    Evidence: B)

4.  Exercise myocardial perfusion SPECT in patients with intermediate
    Duke treadmill score (Level of Evidence: B)

5.  Repeat exercise myocardial perfusion imaging after initial perfusion
    imaging in patients whose symptoms have changed to redefine the risk
    for cardiac event (Level of Evidence: C)

**Class IIa**

1.  Exercise myocardial perfusion SPECT at 3 to 5 years after
    revascularization (either percutaneous coronary intervention \[PCI\]
    or coronary artery bypass graft surgery \[CABG\]) in selected
    high-risk asymptomatic patients (Level of Evidence: B)

2.  Exercise myocardial perfusion SPECT as the initial test in patients
    who are considered to be at high risk (patients with diabetes or
    patients otherwise defined as having a more than 20% 10-year risk of
    a coronary heart disease event) (Level of Evidence: B)

**Class IIb**

1.  Repeat exercise myocardial perfusion SPECT 1 to 3 years after
    initial perfusion imaging in patients with known or a high
    likelihood of CAD and stable symptoms and a predicted annual
    mortality of more than 1% to redefine the risk of a cardiac event
    (Level of Evidence: C)

2.  Repeat exercise myocardial perfusion SPECT on cardiac active
    medications after initial abnormal perfusion imaging to assess the
    efficacy of medical therapy (Level of Evidence: C)

3.  Exercise myocardial perfusion SPECT in symptomatic or asymptomatic
    patients who have severe coronary calcification (computed tomography
    \[CT\] coronary calcium score more than the 75th percentile for age
    and sex) in the presence on the resting ECG of pre-excitation
    \[Wolff-Parkinson-White syndrome\] or more than 1 mm ST-segment
    depression (Level of Evidence: B)

4.  Exercise myocardial perfusion SPECT in asymptomatic patients who
    have a high-risk occupation. (Level of Evidence: B)

**Cardiac Stress Myocardial Perfusion SPECT in Patients Unable to
Exercise**

**Recommendations for Diagnosis of Patients With an Intermediate
Likelihood of CAD and/or Risk Stratification of Patients With an
Intermediate or High Likelihood of CAD Who Are Unable to Exercise.**

**Class I**

1.  Adenosine or dipyridamole myocardial perfusion SPECT to identify the
    extent, severity, and location of ischemia. (Level of Evidence: B)

2.  Adenosine or dipyridamole myocardial perfusion SPECT to assess the
    functional significance of intermediate (25 to 75%) coronary lesions
    (Level of Evidence: B)

3.  Adenosine or dipyridamole myocardial perfusion SPECT after initial
    perfusion imaging in patients whose symptoms have changed to
    redefine the risk for cardiac event (Level of Evidence: C)

**Class IIa**

1.  Adenosine or dipyridamole myocardial perfusion SPECT at 3 to 5 years
    after revascularization (either PCI or CABG) in selected high-risk
    asymptomatic patients (Level of Evidence: B)

2.  Adenosine or dipyridamole myocardial perfusion SPECT as the initial
    test in patients who are considered to be at high risk (patients
    with diabetes or patients otherwise defined as having a more than
    20% 10-year risk of a coronary heart disease event). (Level of
    Evidence: B)

3.  Dobutamine myocardial perfusion SPECT in patients who have a
    contraindication to adenosine or dipyridamole (Level of Evidence: C)

**Class IIb**

1.  Repeat adenosine or dipyridamole myocardial perfusion imaging 1 to 3
    years after initial perfusion imaging in patients with known or a
    high likelihood of CAD and stable symptoms, and a predicted annual
    mortality of more than 1%, to redefine the risk of a cardiac event
    (Level of Evidence: C)

2.  Repeat adenosine or dipyridamole myocardial perfusion SPECT on
    cardiac active medications after initial abnormal perfusion imaging
    to assess the efficacy of medical therapy (Level of Evidence: C)

3.  Adenosine or dipyridamole myocardial perfusion SPECT in symptomatic
    or asymptomatic patients who have severe coronary calcification (CT
    Coronary Calcium Score more than the 75th percentile for age and
    sex) in the presence on the resting ECG of LBBB or an
    electronically-paced ventricular rhythm (Level of Evidence: B)

4.  Adenosine or dipyridamole myocardial perfusion SPECT in asymptomatic
    patients who have a high-risk occupation (Level of Evidence: C)

**Cardiac Stress Myocardial Perfusion Positron Emission Tomography
(PET)**

**Recommendations for Diagnosis of Patients With an Intermediate
Likelihood of CAD and/or Risk Stratification of Patients With an
Intermediate or High Likelihood of CAD**

**Class I**

1.  Adenosine or dipyridamole myocardial perfusion PET in patients in
    whom an appropriately indicated myocardial perfusion SPECT study has
    been found to be equivocal for diagnostic or risk stratification
    purposes (Level of Evidence: B)

**Class IIa**

1.  Adenosine or dipyridamole myocardial perfusion PET to identify the
    extent, severity, and location of ischemia as the initial diagnostic
    test in patients who are unable to exercise (Level of Evidence: B)

2.  Adenosine or dipyridamole myocardial perfusion PET to identify the
    extent, severity, and location of ischemia as the initial diagnostic
    test in patients who are able to exercise but have LBBB or an
    electronically-paced rhythm (Level of Evidence: B)

**Cardiac Stress Perfusion Imaging Before Noncardiac Surgery**

**Recommendations**

**Class I**

1.  Initial diagnosis of CAD in patients with intermediate pretest
    probability of disease and abnormal baseline ECG\* or inability to
    exercise (Level of Evidence: B)

2.  Prognostic assessment of patients undergoing initial evaluation for
    suspected or proven CAD with abnormal baseline ECG\* or inability to
    exercise (Level of Evidence: B)

3.  Evaluation of patients following a change in clinical status (e.g.,
    acute coronary syndrome \[ACS\]) with abnormal baseline ECG\* or
    inability to exercise (Level of Evidence: B)

4.  Initial diagnosis of CAD in patients with LBBB and intermediate
    pretest probability of disease, when used in conjunction with
    vasodilator stress (Level of Evidence: B)

5.  Prognostic assessment of patients with LBBB undergoing initial
    evaluation for suspected or proven CAD, when used in conjunction
    with vasodilator stress (Level of Evidence: B)

6.  Assessment of patients with intermediate or minor clinical risk
    predictors\*\* and poor functional capacity (less than 4 metabolic
    equivalent \[METS\]) who require high-risk noncardiac surgery\*\*\*,
    when used in conjunction with pharmacologic stress (Level of
    Evidence: C)

7.  Assessment of patients with intermediate clinical risk
    predictors\*\*, abnormal baseline ECGs\*, and moderate or excellent
    functional capacity (more than 4 METS) who require high-risk
    noncardiac surgery (Level of Evidence: C)

\*Baseline ECG abnormalities that interfere with interpretation of
exercise-induced ST-segment changes include LBBB, ventricular
pre-excitation, ventricular pacing, LVH with repolarization changes,
more than 1-mm ST depression, and digoxin therapy.

\*\*As defined in the ACC/AHA Guideline Update for Perioperatiave
Cardiovascular Evaluation for Noncardiac Surgery, intermediate clinical
risk predictors include mild angina, prior myocardial infarction (MI),
compensated or prior heart failure, diabetes, and renal insufficiency.
Minor clinical risk predictors include advanced age, abnormal ECG,
rhythm other than sinus, low functional capacity, history of
cerebrovascular accident, and uncontrolled hypertension.

\*\*\*High-risk surgery is defined by emergent operations (particularly
in the elderly), aortic and other major vascular surgery, peripheral
vascular surgery, and other prolonged operations in which major fluid
shifts are anticipated (i.e., reported cardiac risk often more than 5%).

**Class IIb**

1.  Routine assessment of active, asymptomatic patients who have
    remained stable for up to 5 years after CABG surgery (Level of
    Evidence: C)

2.  Routine evaluation of active asymptomatic patients who have remained
    stable for up to 2 years after previous abnormal coronary
    angiography or noninvasive assessment of myocardial perfusion (Level
    of Evidence: C)

3.  Diagnosis of restenosis and regional ischemia in active asymptomatic
    patients within weeks to months after PCI (Level of Evidence: C)

4.  Initial diagnosis or prognostic assessment of CAD in patients with
    right bundle-branch block or less than 1-mm ST depression on resting
    ECG (Level of Evidence: C)

**Class III**

1.  Routine screening of asymptomatic men or women with low pretest
    likelihood of CAD (Level of Evidence: C)

2.  Evaluation of patients with severe comorbidities that limit life
    expectancy or candidacy for myocardial revascularization (Level of
    Evidence: C)

3.  Initial diagnosis or prognostic assessment of CAD in patients who
    require emergency noncardiac surgery (Level of Evidence: C)

**Recommendations for Use of Radionuclide Imaging in Patients With Heart
Failure: Fundamental Assessment**

  --------------------------------------------------------------------------------
  **Indication**                     **Test**             **Class**   **Level of
                                                                      Evidence**
  ---------------------------------- -------------------- ----------- ------------
  1\. Initial assessment of LV and   Rest RNA             I           A
  RV function at rest\*                                               

  2\. Assessment of myocardial       MPI (see Table 5),   I           B
  viability for consideration of     PET                              
  revascularization in patients with                                  
  CAD and LV systolic dysfunction                                     
  who do not have angina                                              

  3\. Assessment of the copresence   MPI                  IIa         B
  of CAD in patients without angina                                   

  4\. Routine serial assessment of   Rest RNA             IIb         B
  LV and RV function at rest                                          

  5\. Initial or serial assessment   Exercise RNA         IIb         B
  of ventricular function with                                        
  exercise                                                            
  --------------------------------------------------------------------------------

\*National consensus treatment guidelines are directed by quantitative
assessment of LVEF and identification of LVEF less than or equal to 40%.

Abbreviations: CAD, coronary artery disease; LV, left ventricular; MPI,
myocardial perfusion imaging; PET, positron emission tomography; RNA,
radionuclide angiography

**Recommendations for the Use of Radionuclide Techniques to Assess
Myocardial Viability**

  -------------------------------------------------------------------------------------------
  **Indication**                **Test**                             **Class**   **Level of
                                                                                 Evidence**
  ----------------------------- ------------------------------------ ----------- ------------
  1\. Predicting improvement in Stress/redistribution/reinjection    I           B
  regional and global LV        ^201^TI                                          
  function after                                                                 
  revascularization                                                              

                                Rest-redistribution imaging          I           B

                                Perfusion plus PET FDG imaging       I           B

                                Resting sestamibi imaging            I           B

                                Gated SPECT sestamibi imaging        IIa         B

                                Late ^201^Tl redistribution imaging  IIb         B
                                (after stress)                                   

                                Dobutamine RNA                       IIb         C

                                Postexercise RNA                     IIb         C

                                Postnitroglycerin RNA                IIb         C

  2\. Predicting improvement in Perfusion plus PET FDG imaging       IIa         B
  heart failure symptoms after                                                   
  revascularization.                                                             

  3\. Predicting improvement in ^201^TI imaging (rest-redistribution I           B
  natural history after         and                                              
  revascularization             stress/redistribution/reinjection)               

                                Perfusion plus PET FDG imaging       Ia          B
  -------------------------------------------------------------------------------------------

Abbreviations: FDG, flurodeoxyglucose; PET, positron emission
tomography; RNA, radionuclide angiography; SPECT, single-photon emission
computed tomography; ^201^Tl, thallium-201

**Recommendations for the Use of Radionuclide Imaging to Diagnose
Specific Causes of Dilated Cardiomyopathy**

  -----------------------------------------------------------------------------------
  **Indication**                     **Test**                **Class**   **Level of
                                                                         Evidence**
  ---------------------------------- ----------------------- ----------- ------------
  1\. Baseline and serial monitoring Rest RNA                I           A
  of LV function during therapy with                                     
  cardiotoxic drugs (e.g.,                                               
  doxorubicin)                                                           

  2\. RV dysplasia                   Rest RNA                IIa         B

  3\. Assessment of posttransplant   Exercise perfusion      IIb         B
  obstructive CAD                    imaging                             

  4\. Diagnosis and serial           Exercise perfusion      IIb         B
  monitoring of Chagas disease       imaging                             

  5\. Diagnosis of amyloid heart     ^99m^Tc-pyrophosphate   IIb         B
  disease                            imaging                             

  6\. Diagnosis and serial           Rest perfusion imaging  IIb         B
  monitoring of sarcoid heart                                            
  disease                                                                

                                     Rest ^67^Ga imaging     IIb         B

  7\. Detection of myocarditis       Rest ^67^Ga imaging     IIb         B

                                     ^111^In antimyosin      IIb         C
                                     antibody imaging                    
  -----------------------------------------------------------------------------------

Abbreviations: ^67^Ga, gallium-67; ^99m^Tc-pyrophosphate,
Tc-99m-pyrophosphate; ^111^In, indium-111; CAD, coronary artery disease;
LV, left ventricular; RNA, radionuclide angiography; RV, right
ventricular

**Recommendations for the Use of Radionuclide Imaging to Evaluate
Hypertrophic Heart Disease**

  --------------------------------------------------------------------------------
  **Indication**                     **Test**             **Class**   **Level of
                                                                      Evidence**
  ---------------------------------- -------------------- ----------- ------------
  1\. Diagnosis of CAD in            Rest and exercise    IIb         B
  hypertrophic cardiomyopathy        perfusion imaging                

  2\. Diagnosis and serial           Rest RNA             IIb         B
  monitoring of hypertensive                                          
  hypertrophic heart disease                                          

  3\. Diagnosis and serial           Rest RNA             III         B
  monitoring of hypertrophic                                          
  cardiomyopathy, with and without                                    
  outflow obstruction                                                 
  --------------------------------------------------------------------------------

Abbreviations: CAD, coronary artery disease; RNA, radionuclide
angiography

**Recommendations for the Use of Radionuclide Imaging in Valvular Heart
Disease**

  --------------------------------------------------------------------------------
  **Indication**                     **Test**             **Class**   **Level of
                                                                      Evidence**
  ---------------------------------- -------------------- ----------- ------------
  1\. Initial and serial assessment  Rest RNA             I           B
  of LV and RV function                                               

  2\. Initial and serial assessment  Exercise RNA         IIb         B
  of LV function                                                      

  3\. Assessment of the copresence   MPI                  IIb         B
  of coronary disease                                                 
  --------------------------------------------------------------------------------

Abbreviations: LV, left ventricular; RNA, radionuclide imaging
angiography; RV, right ventricular; MPI, myocardial perfusion imaging

**Recommendations for the Use of Radionuclide Imaging in Adults with
Congenital Heart Disease**

  --------------------------------------------------------------------------------
  **Indication**                     **Test**             **Class**   **Level of
                                                                      Evidence**
  ---------------------------------- -------------------- ----------- ------------
  1\. Initial and serial assessment  Rest RNA             I           B
  of LV and RV function                                               

  2\. Shunt detection and            FPRNA                IIa         B
  quantification                                                      
  --------------------------------------------------------------------------------

Abbreviations: FPRNA, first-pass radionuclide angiography; LV, left
ventricular; RV, right ventricular; RNA, radionuclide angiography

**Definitions**:

**Class I**: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and effective

**Class II**: Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness/efficacy of a procedure or
treatment

**Class IIa**: Weight of evidence/opinion is in favor of
usefulness/efficacy

**Class IIb**: Usefulness/efficacy is less well established by
evidence/opinion

**Class III**: Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful/effective and in
some cases may be harmful

**Strength of Evidence**

A.  Data derived from multiple randomized clinical trials

B.  Data derived from a single randomized trial, or from nonrandomized
    trials

C.  Consensus opinion of experts

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Recommendations in this guideline are derived from the literature search
results. The type of supporting evidence is identified with each
recommendation (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate use of testing and technology in the diagnosis and
    treatment of patients with known or suspected cardiovascular disease

-   Decreased morbidity and mortality associated with cardiovascular
    disease due to contribution of radionuclide imaging studies in the
    diagnosis, assessment of severity of disease/risk
    assessment/prognosis, and assessment of therapy

#### POTENTIAL HARMS

**Dipyridamole and Adenosine**

Both dipyridamole and adenosine are safe and well tolerated despite
frequent mild side effects, which occur in 50% and 80% of patients,
respectively. With dipyridamole infusion, the most common side effect is
chest pain (18 to 42%), with arrhythmia occurring in less than 2%.
Noncardiac side effects have included headache (5 to 23%), dizziness (5
to 21%), nausea (8 to 12%), and flushing (3%). With adenosine infusion,
chest pain has been reported in 57%, headache in 35%, flushing in 25%,
shortness of breath in 15%, and first-degree atrioventricular block in
18%. The side effects of adenosine or dipyridamole are less frequent
when vasodilator stress is combined with low-level exercise.
Dipyridamole and adenosine side effects are antagonized by theophylline;
however, this drug is ordinarily not needed after adenosine because of
the latter\'s ultrashort half-life (less than 10 seconds). The ability
of these drugs to cause coronary vasodilation can be blocked by caffeine
and other methylxanthines. Thus, patients are instructed to avoid these
agents for 24 hours before testing.

**Dobutamine**

Although side effects are frequent during dobutamine infusion, the test
appears to be relatively safe, even in the elderly. The most frequently
reported noncardiac side effects (total 26%) in a study of 1,118
patients included nausea (8%), anxiety (6%), headache (4%), and tremor
(4%) (497). Common arrhythmias included premature ventricular beats
(15%), premature atrial beats (8%), supraventricular tachycardia, and
nonsustained ventricular tachycardia (3 to 4%). Atypical chest pain was
reported in 8%, and angina pectoris in approximately 20%.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Severe side effects are rare, but both dipyridamole and adenosine may
cause severe bronchospasm in patients with asthma or reactive airway
disease; therefore, they are contraindicated in these patients.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These practice guidelines are intended to assist physicians and
    other qualified healthcare professionals in clinical decision making
    by describing a range of generally acceptable approaches for the
    diagnosis, management, or prevention of specific diseases or
    conditions. These guidelines attempt to define practices that meet
    the needs of most patients in most circumstances. The ultimate
    judgment regarding care of a particular patient must be made by the
    physician and patient in light of all of the circumstances presented
    by that patient.

-   This report overlaps with several previously published American
    College of Cardiology/American Heart Association (ACC/AHA)
    guidelines for patient treatment that potentially involve cardiac
    radionuclide imaging. These include published guidelines for chronic
    stable angina (SA; 2002), unstable angina and non-ST-elevation
    myocardial infarction (UA/NSTEMI; 2002), heart failure (2001),
    perioperative cardiovascular evaluation for noncardiac surgery
    (2002), exercise testing (2002), valvular heart disease (1998), and
    acute myocardial infarction (AMI; 1999). The present report is not
    intended to include information previously covered in these
    guidelines, or to provide a comprehensive treatment of the topics
    addressed in these guidelines.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide
imaging: a report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines (ACC/AHA/ASNC Committee to
revise the 1995 guidelines \[trunc\]. Bethesda (MD): American College of
Cardiology Foundation; 2003. 69 p. \[519 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1995 Feb (revised 2003 Aug)

#### GUIDELINE DEVELOPER(S)

American College of Cardiology Foundation - Medical Specialty Society\
American Heart Association - Professional Association\
American Society of Nuclear Cardiology - Professional Association

#### SOURCE(S) OF FUNDING

The American College of Cardiology and the American Heart Association.
No outside funding accepted.

#### GUIDELINE COMMITTEE

American College of Cardiology (ACA)/American Heart Association
)AHA)/American Society of Nuclear Cardiology (ASNC) Committee to Revise
the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

The committee membership consisted of acknowledged experts in
radionuclide testing, as well as general cardiologists and cardiologists
with expertise in other imaging modalities: both the academic and
private practice sectors were represented.

*Committee Members*: Francis J. Klocke, MD, MACC, FAHA (Chair); Michael
G. Baird, MD, FACC, FAHA; Timothy M. Bateman, MD, FACC, FAHA; Daniel S.
Berman, MD, FACC, FAHA; Blase A. Carabello, MD, FACC, FAHA; Manuel D.
Cerqueira, MD, FACC, FAHA; Anthony N. DeMaria, MD, MACC, FAHA; J. Ward
Kennedy, MD, MACC, FAHA; Beverly H. Lorell, MD, FACC, FAHA; Joseph V.
Messer, MD, MACC, FAHA; Patrick T. O\'Gara, MD, MACC, FAHA; Richard O.
Russell, Jr., MD, FACC; Martin G. St. John Sutton, MBBS, FACC; James E.
Udelson, MD, FACC; Mario S. Verani, MD, FACC\*; Kim Allan Williams, MD,
FACC, FAHA

*Task Force Members*: Elliott M. Antman, MD, FACC, FAHA (Chair); Sidney
C. Smith, Jr., MD, FACC, FAHA (Vice Chair); Joseph S. Alpert, MD, FACC,
FAHA; Gabriel Gregoratos, MD, FACC, FAHA; Jeffrey L. Anderson, MD, FACC;
David P. Faxon, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA;
Raymond J. Gibbons, MD, FACC, FAHA\*\*#; Loren F. Hiratzka, MD, FACC,
FAHA; Sharon Ann Hunt, MD, FACC, FAHA; Alice K. Jacobs, MD, FACC, FAHA;
Richard O. Russell, MD, FACC, FAHA\*\*

\*Deceased\
\*\*Former Task Force Member\
#Former Task Force Chair

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The American College of Cardiology/American Heart Association Task Force
on Practice Guidelines makes every effort to avoid any actual or
potential conflicts of interest that might arise as a result of an
outside relationship or personal interest of a member of the writing
panel. Specifically, all members of the writing panel are asked to
provide disclosure statements of all such relationships that might be
perceived as real or potential conflicts of interest. These statements
are reviewed by the parent task force, reported orally to all members of
the writing panel at the first meeting, and updated as changes occur.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Ritchie JL, Bateman TM, Bonow
RO, Crawford MH, Gibbons RJ, Hall RJ, O\'Rourke RA, Parisi AF, Verani
MS. Guidelines for clinical use of cardiac radionuclide imaging. Report
of the American College of Cardiology/American Heart Association Task
Force on Assessment of Diagnostic and Therapeutic Cardiovascular
Procedures (Committee on Radionuclide Imaging), J Am Coll Cardiol 1995
Feb;25(2):521-47.

These guidelines will be reviewed 1 year after publication and yearly
thereafter and considered current unless the Task Force on Practice
Guidelines revises or withdraws them from circulation.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Cardiology (ACC) Web
site](http://www.acc.org/qualityandscience/clinical/guidelines/radio/index.pdf).

Copies are also available from the [American Heart Association (AHA) Web
site](http://www.americanheart.org/downloadable/heart/1061222494555RNIFullTextFinal.pdf).

Print copies: Available from ACC, Educational Services, 9111 Old
Georgetown Road, Bethesda, MD 20814-1699. Also available from AHA,
Public Information 7272 Greenville Avenue, Dallas, TX 75231-4596
(Reprint No. 71-0112).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide
    imaging\--executive summary: a report of the American College of
    Cardiology/American Heart Association Task Force on Practice
    Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for
    the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll
    Cardiol. 2003 Oct 1;42(7):1318-33; Circulation. 2003 Sep
    16;108(11):1404-18.

Electronic copies: Available from the American College of Cardiology
(ACC) Web site in [Portable Document Format
(PDF)](http://www.acc.org/qualityandscience/clinical/guidelines/radio/exec_summary.pdf).

Print copies: Available from ACC, Educational Services, 9111 Old
Georgetown Road, Bethesda, MD 20814-1699. Also available from AHA,
Public Information 7272 Greenville Avenue, Dallas, TX 75231-4596
(Reprint No. 71-0112).

#### PATIENT RESOURCES

None provided

#### NGC STATUS

This summary was completed by ECRI on June 30, 1998. The information was
verified by the guideline developer on December 1, 1998. This summary
was updated by ECRI on March 5, 2004. The updated information was
verified by the guideline developer on May 13, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions as follows:

Copyright to the original guideline is owned by the American College of
Cardiology Foundation (ACCF) and the American Heart Association, Inc.
(AHA). NGC users are free to download a single copy for personal use.
Reproduction without permission of the ACC/AHA guidelines is prohibited.
Permissions requests should be directed to Patty Jones, 9111 Old
Georgetown Rd, Bethesda, MD 20814-1699; telephone, (800) 253-4636 ext.
368; fax, (301) 897-9745.

### DISCLAIMER

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Date Modified: 11/3/2008