Responsible growth of nuclear cardiology in Spain
Responsible growth of nuclear cardiology in Spain
Maria Joa˜o Ferreira 0 4
Manuel D. Cerqueira 0
MASNC 0 1 2 3
0 Reprint requests: Manuel D. Cerqueira , MD, FACC, MASNC , Cleveland Clinic Lerner College of Medicine, Case Western Reserve University , 9500 Euclid Ave, Cleveland, OH 44195; J Nucl Cardiol 2017;24:2141-3. 1071-3581/ $34.00 Copyright 2017 American Society of Nuclear Cardiology
1 Heart and vascular Institute, Cleveland Clinic , Cleveland, OH , USA
2 Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland Clinic , Cleveland, OH , USA
3 Department of Nuclear Medicine, Imaging Institute, Cleveland Clinic , Cleveland, OH , USA
4 Faculdade de Medicina, Centro Hospitalar e Universita ́rio de Coimbra, Universidade de Coimbra , Coimbra , Portugal
After 50 years of clinical use, nuclear cardiology
maintains an important worldwide role in the diagnosis
and management of patients with known or suspected
heart disease.1 Coronary artery disease is an important
and common cause of mortality and morbidity
worldwide and in Europe accounts for death in 19% of men
and 20% of women.2,3 There have been significant
advances in single photon emission computed
tomography (SPECT) myocardial perfusion imaging (MPI)
instrumentation, available radiotracers, and a growing
importance on the use of positron emission tomography
(PET) for assessment of ischemia, viability, infection,
inflammation and identification of microvascular and
balanced coronary artery disease.4
The paper from Jimenez-Hefferna et al in this issue
describes nuclear cardiology activity and resources in
Spain in 2014.5 The data is based on the results of an
online questionnaire developed and distributed by the
Nuclear Cardiology Working Group of the Spanish
Society of Nuclear Medicine and Molecular Imaging.
The use of such online questionnaires should be
encouraged as they give valuable information which can
be a source for continuous quality improvement.
The results presented were based on the information
from 42 nuclear medicine departments that responded.
The respondents were distributed throughout all regions
of Spain, 32 were in public hospitals and 10 were from
private practices. Of the 32 public centers, 78% were in
university hospitals and served 39% of the entire
Spanish population. The results show that nuclear
cardiology represents 15% of all nuclear medicine exams in
Spain in 2014: MPI, 69%; equilibrium ventriculography,
17%; FDG PET, 12%; first pass ventriculography, 1.3%;
and mIBG and diphosphono-propanodicarboxyicacid
imaging for amyloidosis, \1%. The total of 15% for
nuclear cardiology is low in comparison to the average
of 50% commonly reported in the US. The yearly
number of MPI studies performed varied from 26 to
2,727 per center with 26% of the centers performing less
than 250 patients yearly. Thirty-eight percent of the
centers operated with two gamma cameras to perform all
the nuclear medicine studies. Half of the centers used
computed tomography for attenuation correction. All the
centers used Tc-99m tracers and 16% were still using
201-Tl. Nuclear cardiology exams were referred by
cardiologists in 88% of studies. Study interpretation and
reporting were performed solely by nuclear medicine
physicians in 70% of cases and in 30% done in
collaboration with cardiologists by nuclear medicine
The authors conclude that nuclear cardiology in
Spain is performed according to international standards.
Significant improvements can be achieved by adoption
of high sensitivity, low dose dedicated cardiac SPECT
cameras, and the increased use of cardiac PET.
There are several areas of concern that are not fully
addressed in the work presented:
) What % of all nuclear medicine services in Spain do
the 42 responding sites represent?
) Given the concerns for lowering radiation exposure,
why are thallium and 2-day studies still being
performed? Are patients being evaluated for the
appropriateness of the indications?
) What can be done to increase the use of cardiac
) Are optimal laboratory quality standards being met?
) Is the full potential of nuclear cardiology being
utilized in Spain?
WHAT % OF ALL NUCLEAR MEDICINE SERVICES
IN SPAIN DO THE 42 RESPONDING SITES
It is important to know what sites were not sampled
by the survey due to nonresponse. Of the 32 public
hospitals reporting, 25 were university affiliated sites
and accounted for 39% of all the nuclear medicine
studies performed in Spain in 2014. It was also shown
that 26% of centers performed \250 nuclear cardiology
studies/year with at least one site performing only 26
yearly. Thus, there is concern that the best sites were
over represented and a broader sampling is required to
fully understand the full scope of practice of nuclear
cardiology in Spain. Sampling of better sites is
suggested by the fact that 50% of sites had SPECT/CT
systems and 26% had PET/CT. These percentages are
much higher than reported in other areas of the world.
GIVEN THE CONCERNS FOR LOWERING
RADIATION EXPOSURE, WHY ARE THALLIUM
AND 2-DAY STUDIES STILL BEING PERFORMED?
ARE PATIENTS BEING EVALUATED FOR THE
APPROPRIATENESS OF THE INDICATIONS?
The authors advocate greater use of high sensitivity
SPECT cameras and PET systems to lower radiation
exposure, but at least 16% of sites responding were still
using thallium and 63% of sites were using 2-day stress/
rest Tc-99m protocols. We are told that 63% of sites
offered stress-only protocols, but it is not clear what %
of 2-day study patients did not return for the rest portion.
Hospital budgets for new imaging equipment are limited
in all countries and CZT crystal SPECT cameras and
PET systems may not be readily available. In the
meantime, advocating for the use of Tc-99m agents and
stress-only protocols needs to be emphasized. In
addition, the use of Appropriate Use Criteria needs to be
Journal of Nuclear Cardiology
advocated as this is the most effective way to reduce
Europe uses the lowest effective radiation doses
compared with other countries of the world. Partially,
this could be justified by existing European
Regulations.7 However, there was regional variation in Europe.
In southern Europe, which includes Spain, higher
radiation doses are reported in the performance of
nuclear cardiology exams. PET, attenuation correction
and stress-only studies are also performed less often in
WHAT CAN BE DONE TO INCREASE THE USE OF
CARDIAC PET IN SPAIN?
Growth as advocated by the authors is unlikely to
occur unless inexpensive PET radiotracers and camera
systems can be made available. Rb-82 generator systems
or onsite cyclotrons for N-13 ammonia or O-15 water for
low volume laboratories, as exist in Spain, are cost
prohibitive. PET perfusion imaging is not being
performed at any of the responding sites and the 12%
cardiac PET studies reported were all using FDG. Ways
to make the expensive PET perfusion tracers more
available include development of less expensive Rb-82
generator systems or using a mobile generator that could
be taken on a rotating system to multiple hospitals in a
city that may have capacity on oncology PET systems.
Small dedicated cyclotron systems also can produce
N13 ammonia at a lower cost and could be used at select
centers that have high cardiac volumes.
F-18 radiolabeled perfusion tracers are in
development and if approved could take advantage of the
existing cyclotron infrastructure developed for
production and distribution of F-18 FDG for tumor imaging to
make a unit dose PET perfusion tracer available. This
would optimize efficiency of existing PET cameras and
allow applications in nuclear cardiology in many more
ARE OPTIMAL LABORATORY QUALITY
STANDARDS BEING MET?
Nuclear cardiology laboratory quality standards or
accreditation do not guarantee optimal performance, but
guarantee that minimum standards for equipment,
protocols, physician training, and reports are being met. It is
not clear from the data presented that any of the
laboratories were being held to such standards.
One important accreditation measure is the ordering
and reporting of nuclear cardiology examinations as
described by the Cardiovascular Committee of the
European Association of Nuclear Medicine and the
Section on Nuclear Cardiology and Cardiac Computed
Tomography of the European Association of
Cardiovascular Imaging of the European Society of Cardiology.8 It
was highly recommended that there be communication
between the nuclear medicine physician and referring
cardiologist not only in the referral but also in
communicating the outcome of the test.8 In the paper from
Jimenez-Hefferna et al, only 30% of nuclear cardiology
procedures were interpreted and reported by nuclear
medicine physicians in collaboration with cardiologists.5
Laboratory accreditation and optimal communication
between nuclear medicine physicians and cardiologists
in the ordering and reporting of nuclear cardiology
studies are necessary for optimal results.4,8
IS THE FULL POTENTIAL OF NUCLEAR
CARDIOLOGY BEING UTILIZED IN SPAIN?
Although assessment of myocardial ischemic
disease by MPI is the main use of nuclear cardiology, there
are other studies that can be useful in the diagnosis and
management of heart failure, arrhythmias, sudden
cardiac death, infection, and inflammation. Infection and
inflammation are well represented by the 12% FDG use,
but all other areas represent only \1% of the volume
reported in the responding laboratories in Spain.
Techniques are available for evaluation of cardiac
amyloidosis using diphosphono-propanodicarboxyicacid
or any of the available PET agents for amyloid plaque
imaging in Alzheimer’s. Myocardial sympathetic
innervation can be imaged using I-123 mIBG but despite
recent large trails showing risk stratification, it has not
been used widely.
Recently, the European guidelines on infective
endocarditis recommend the use of PET-CT or
SPECT-CT studies with 18F-FDG or autologous
radiolabelled leucocytes in patients with possible endocarditis
according to the diagnostic criteria or in the detection of
peripheral embolic or metastatic infectious events.9
Nuclear cardiology continues to be a vital part of
cardiac patient management in Spain. This study shows
that there are areas where improvements can be made in
terms of further radiation reduction, implementation of
new radiotracers, and technology and increases in less
commonly performed procedures. Nuclear cardiology
remains an expanding and exciting field where
limitations can be overcome with new dedicated, high
sensitivity gamma cameras and new PET and SPECT
tracers. The use of best practice criteria with
collaboration between nuclear medicine physicians and
cardiologists should be encouraged not only in patient
The authors declare that they have no conflict of interest.
referral but also in exam performance and reporting.
Less commonly performed but important diagnostic
procedures should be explored and promoted with the
intent of generating evidence-based data on volumes,
accuracy, and outcomes.
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