Diagnostic accuracy of artificial intelligence-enabled vectorcardiography versus myocardial perfusion SPECT in patients with suspected or known coronary heart disease.

AIM: The present study evaluated with myocardial perfusion SPECT (MPS) the diagnostic accuracy of an artificial intelligence-enabled vectorcardiography system (Cardisiography, CSG) for detection of perfusion abnormalities. METHODS: We studied 241 patients, 155 with suspected CAD and 86 with known CAD who were referred for MPS. The CSG was performed after the MPS acquisition. The CSG results (1) p-factor (perfusion, 0: normal, 1: mildly, 2: moderately, 3: highly abnormal) and (2) s-factor (structure, categories as p-factor) were compared with the MPS scores. The CSG system was not trained during the study. RESULTS: Considering the p-factor alone, a specificity of >78% and a negative predictive value of mostly >90% for all MPS variables were found. The sensitivities ranged from 17 to 56%, the positive predictive values from 4 to 38%. Combining the p- and the s-factor, significantly higher specificity values of about 90% were reached. The s-factor showed a significant correlation (p=0.006) with the MPS ejection fraction. CONCLUSIONS: The CSG system is able to exclude relevant perfusion abnormalities in patients with suspected or known CAD with a specificity and a negative predictive value of about 90% combining the p- and the s-factor. Since it is a learning system there is potential for further improvement before routine use.

Patients with Artificial Heart Valves.

BACKGROUND: In Germany, a total of 38 547 heart valve procedures were performed in 2022. With a growing number of patients undergoing the surgical and interventional implantation of heart valves, the incidence of prosthetic endocarditis is also rising. METHODS: We summarize the current state of the prophylaxis, diagnosis, and treatment of prosthetic endocarditis in a selective review of the literature. RESULTS: Prosthetic endocarditis accounts for 10-30% of all cases of endocarditis. As its echocardiographic and microbiologic findings are often less specific than those of native endocarditis, its diagnosis now increasingly relies on alternative imaging modalities such as F-18-FDG PET-CT. Anti-infective and surgical treatment are made more difficult by biofilm formation on the prosthetic valve and the frequent formation of perivalvular abscesses. CONCLUSION: Increased awareness of this clinical entity in the outpatient setting will promote the earlier initiation of appropriate diagnostic studies. Proper diagnostic evaluation is an essential prerequisite for the early detection and timely treatment of prosthetic endocarditis, with the goal of preventing progressive destruction and thus improving the outcome. Preventive and educative measures should be intensified, and certified, multidisciplinary endocarditis teams should be established. Antibiotic prophylaxis is now given much more restrictively than in earlier years; the risk of infection must be weighed against the potential development of both individual and collective resistance to antibiotic drugs.

Myocardial Perfusion SPECT and ATTR imaging 2021 in Germany: Results of the 9th Survey.

AIM: This paper presents the results of the 9th survey of myocardial perfusion SPECT (MPS) from the reporting year 2021. METHODS: 218 questionnaires (131 practices (PR), 58 hospitals (HO), 29 university hospitals (UH)) were evaluated. Results of the last survey 2018 are set in squared brackets. RESULTS: MPS data from a total of 133,057 [145,930] patients (-8.8%) with 131,868 [143,707] stress and 106,546 [121,899] rest MPS were analysed. A comparison with official data revealed that 54% all MPS were recorded. From 2018 to 2021, official data showed a every year an increase in MPS numbers. On average, 610 [502] MPS patients (+22%) were examined in each department. 74% [69%] of the responders reported an increase or no changes in their MPS patient numbers. Ambulatory care cardiologists represented as always, the mayor referral group (68% [69%]). For the first time, pharmacological stress was more frequently applied than ergometry (42% [51]). Regadenoson was mostly used. The use of the different protocols remained nearly unchanged. Two-day protocols were predominantly applied (49% [48%]). A shift from multi-headed cameras (58% [72%]) to SPECT-CT systems (24% [17%]) was found. Attenuation correction was performed in 33% [26%] of all MPS. 88% [86%] of all stress, 88% [87%] of all rest and 87% [83%] of all stress and rest MPS were acquired as gated SPECT. 72% [67%] of all departments performed scoring by default. The number of departments without scoring decreased to 13% [16%]. CONCLUSIONS: The MPS Study 2021 shows that the long-term positive development of MPS imaging in Germany is continuing. The COVID-19 pandemia did not change this trend. The procedural and technical details of MPS imaging reveal a high level of guideline conformity.

Teaching of Nuclear Cardiology in Times of Pandemic: Transfer of a Case-based Interactive Course from Classroom to Distance Learning.

AIM: While methods of independent study, such as problem-based learning, have been shown beneficial to students' learning outcome and motivation to self-educate, these concepts are currently challenged by the pandemic. The aim of the current study was the evaluation of the transfer of an interactive nuclear cardiology teaching module to an online, distance learning setting. METHODS: Two-hundred-forty medical students completed and evaluated the teaching module in a classroom and 127 students in the distance learning setting. RESULTS: The interactive, problem-based teaching module was transferred well into the distance learning setting during the pandemic. However, while the presented results suggest that distance learning is a good substitute for classroom teaching when in-person teaching is not possible, the distance teaching module was perceived less efficient in its course didactics, demands as well as applicability than the same module in a classroom setting. CONCLUSION: Although distance learning thus cannot entirely replace classroom education, it does provide a well-suited alternative method to teach particularly nuclear medicine and medicine in general. Future applications should offer introductory sessions, provide learning materials in advance and slow down the teaching pace to facilitate online, distance learning.

18F-GP1 Positron Emission Tomography and Bioprosthetic Aortic Valve Thrombus.

BACKGROUND: Bioprosthetic valve thrombosis may have implications for valve function and durability. OBJECTIVES: Using a novel glycoprotein IIb/IIIa receptor radiotracer 18F-GP1, we investigated whether positron emission tomography (PET)-computed tomography (CT) could detect thrombus formation on bioprosthetic aortic valves. METHODS: Ex vivo experiments were performed on human platelets and explanted bioprosthetic aortic valves. In a prospective cross-sectional study, patients with either bioprosthetic or normal native aortic valves underwent echocardiography, CT angiography, and 18F-GP1 PET-CT. RESULTS: Flow cytometric analysis, histology, immunohistochemistry, and autoradiography demonstrated selective binding of 18F-GP1 to activated platelet glycoprotein IIb/IIIa receptors and thrombus adherent to prosthetic valves. In total, 75 participants were recruited: 53 with bioprosthetic valves (median time from implantation 37 months [IQR: 12-80 months]) and 22 with normal native aortic valves. Three participants had obstructive valve thrombosis, and a further 3 participants had asymptomatic hypoattenuated leaflet thickening on CT angiography. All bioprosthetic valves, but none of the native aortic valves, demonstrated focal 18F-GP1 uptake on the valve leaflets: median maximum target-to-background ratio 2.81 (IQR: 2.29-3.48) vs 1.43 (IQR: 1.28-1.53) (P < 0.001). Higher 18F-GP1 uptake was independently associated with duration of valve implantation and hypoattenuated leaflet thickening. All 3 participants with obstructive valve thrombosis were anticoagulated for 3 months, leading to resolution of their symptoms, improvement in mean valve gradients, and a reduction in 18F-GP1 uptake. CONCLUSIONS: Adherence of activated platelets is a common and sustained finding on bioprosthetic aortic valves. 18F-GP1 uptake is higher in the presence of thrombus, regresses with anticoagulation, and has potential use as an adjunctive clinical tool. (18F-GP1 PET-CT to Detect Bioprosthetic Aortic Valve Thrombosis; NCT04073875).

Attenuation correction in CZT myocardial perfusion imaging comparison of supine-prone and low-dose CT-corrected supine acquisitions.

AIMS: The study aimed to investigate whether additional prone imaging delivers comparable results to supine imaging with low-dose computed tomography (CT) attenuation correction (CTAC) in cadmium, zinc and telluride (CZT) myocardial perfusion imaging. METHODS AND RESULTS: Thirty-four patients with an indication for myocardial perfusion imaging were studied with a CZT camera in the supine and then prone position. Furthermore, a low-dose CT was acquired. Three data sets were reconstructed and considered for analysis: (1) supine CZT, (2) supine CZT with CTAC and (3) supine CZT with additional prone CZT. Based on 17-segment polartomograms, we compared radiopharmaceutical uptake percentage, summed stress score (SSS), summed rest score (SRS), summed difference score (SDS), total ischemic and scarred segments, and finally scan classification and clinical decision-making. SSS of supine/supine-CTAC/supine-prone was 341/229/253 (P < 0.05), SRS was 246/156/164 (P < 0.05) and SDS was 104/88/96 (ns), respectively. Total ischemic segments were 65/67/65 (ns) and total scarred segments 96/62/69 (P < 0.05), respectively. The frequency of normal scans was highest for supine-prone, followed by supine-CTAC and supine (41/35/24%, respectively). Supine imaging indicated 23% of patients for invasive coronary angiography, both supine-CTAC and supine-prone 18%. These two showed a significant intercorrelation. CONCLUSION: Additional prone imaging and CTAC are mainly correct for the amount and extent of myocardial scars. Both methods increase the frequency of normal scans and show a significant agreement in clinical decision-making. Additional prone imaging appears as a useful alternative when a low-dose CT for attenuation correction is not available.

Myocardial Perfusion SPECT 2018 in Germany: Results of the 8th Survey.

AIM: This paper presents the results of the 8th survey of myocardial perfusion SPECT (MPS) from the reporting year 2018. METHODS: 291 questionnaires (184 practices (PR), 77 hospitals (HO), 30 university hospitals (UH)) were evaluated. Results of the last survey from 2015 are set in squared brackets. RESULTS: MPS of 145 930 [121 939] patients were reported (+ 19.6 %). 76 % [78 %] of all patients were studied in PR, 16 % [14 %] in HO, and 8 % [8 %] in UH, mostly with a 2-day-protocol 48 % [50 %]. 99.96 % [98 %] of all MPS were performed with Tc-99 m radiopharmaceuticals and in 0.04 % with Tl-201.A pharmacological stress test was applied in 49 % [43 %] (23 % [22 %] adenosine, 26 % [20 %] regadenoson, dipyridamole or dobutamine together < 1 % [1 %]). Attenuation correction was performed in 26 % [25 %] of all MPS, gated SPECT in 86 % [80 %] of stress MPS, in 87 % [78 %] of rest and in 83 % [76 %] of all stress and rest MPS. 67 % [53 %] of the departments performed MPS scoring by default, whereas 16 % [24 %] did not apply this feature at all.69 % [60 %] reported an increase or no changes in their MPS patient numbers. One hundred twenty-six departments which participated in the surveys from 2009 to 2018 reported an increase in MPS by 44 %. 69 % [70 %] of the MPS were requested by ambulatory care cardiologists. CONCLUSION: The 2018 MPS survey reveals a high-grade adherence of routine MPS practice to current guidelines. The positive development in MPS performance and MPS numbers observed since 2012 remains ongoing.

[Development of a national competency-based learning objective catalogue for undergraduate medical education in Germany]. / Entwicklung eines kompetenzbasierten Lernzielkatalogs Nuklearmedizin für das Studium der Humanmedizin in Deutschland.

AIMS: Implementation of the guidelines on the Competency-based Learning Objective Catalogue for Undergraduate Medical Education for a Nuclear Medicine curriculum on behalf of the committee on professional training and continuing education of the German Association of Nuclear Medicine (DGN) METHODS:: In 7 domains 100 learning objectives (LOs) were subject to a prioritization in 3 categories (A, B and C) by means of a questionnaire as part of a Delphi method, in collaboration with all members of the DGN holding a "venia legendi" as experts. Category A defined the essential LOs for each medical practitioner. The prioritization was made by ranking the frequency of the A-classifications. In the 2nd step of the Delphi method, a list of LOs with the ranking positions 1-5 in each domain was presented to the first round's experts as a core curriculum, asking either for acceptance or modifications. RESULTS: The results of the 1st step of the Delphi method deliver a return rate of 29% of the questionnaires (55 out of 184). The 2nd round shows a return rate of 30.9% (57 out of 184) and full approval of the proposed LOs in all LO domains by in median 72 % of the experts consulted (61%-81%). The present final version contains 37 competency-based LOs in the LO domains "legal basis and radiation protection", "basic science", indications and contra-indications for "PET/CT", "scintigraphy and SPECT", "patient preparation", "image interpretation" as well as "therapy". CONCLUSION: The Competency-based Learning Objective Catalogue for Nuclear Medicine describes the knowledge and competencies, every physician should have at the end of his medical studies. The LO catalogue is a living document, which needs to be adapted continuously to the progress of the medical and technological development.

[Policy paper nuclear cardiology - update 2018 - Current status of clinical practice]. / Positionspapier Nuklearkardiologie ­ Update 2018.

The joint position paper of the working community "Cardiovascular Nuclear Medicine" of the German Society of Nuclear Medicine (DGN) and the working group "Nuclear Cardiology Diagnostics" of the German Cardiac Society (DKG) updates the former 2009 paper. It is the purpose of this paper to provide an overview about the application fields, the state-of-the-art and the current value of nuclear cardiology imaging. The topics covered are chronic coronary artery disease, including viability imaging, furthermore cardiomyopathies, infective endocarditis, cardiac sarcoidosis and amyloidosis.

The Diagnosis of Chronic Coronary Heart Disease.

BACKGROUND: Chronic coronary heart disease (CHD) and acute myocardial infarction are endemic conditions. In Germany, an estimated 900 000 cardiac catheterizations were performed in the year 2014, and a percutaneous intervention was carried out in 40% of these procedures. It would be desirable to lessen the number of invasive diagnostic procedures while preserving the reliability of diagnosis. In this article, we present the updated recommendations of the German National Care Guideline for Chronic CHD with regard to diagnostic evaluation. METHODS: Updated recommendations for the diagnostic evaluation of chronic CHD were developed on the basis of existing guidelines and a systematic literature review and approved by a formal consensus process. RESULTS: 8-11% of patients with chest pain who present to a general practitioner and 20-25% of those who present to a cardiologist have chronic CHD. General practitioners should estimate the probability of CHD with the Marburg Heart Score. Specialists can use detailed tables for determining the pre-test probability of CHD; if this lies in the range of 15% to 85%, then non-invasive tests should be primarily used for evaluation and treatment planning. If the pretest probability is less than 15%, other potential causes should be ruled out first. If it is over 85%, the presence of CHD should be presumed and treatment planning should be initiated. Coronary angiography is needed only if therapeutic implications are expected (revascularization). Psychosocial risk factors for the development and course of CHD and the patient's quality of life should be regularly assessed as well. CONCLUSION: Non-invasive testing and invasive coronary angiography should be used only if their findings are expected to have therapeutic implications. Psychosocial risk factors, the quality of life, and adherence to treatment are important components of these patients' diagnostic evaluation and long-term care.

[Myokard-Perfusions-SPECT. Myocardial perfusion SPECT - Update S1 guideline]. / Myokard-Perfusions-SPECT. Update S1-Leitlinie1.

The S1 guideline for myocardial perfusion SPECT has been published by the Association of the Scientific Medical Societies in Germany (AWMF) and is valid until 2/2022. This paper is a short summary with comments on all chapters and subchapters wich were modified and amended.

Systematic review of cost-effectiveness of myocardial perfusion scintigraphy in patients with ischaemic heart disease: A report from the cardiovascular committee of the European Association of Nuclear Medicine. Endorsed by the European Association of Cardiovascular Imaging.

Coronary artery disease (CAD) is a major cause of death and disability. Several diagnostic tests, such as myocardial perfusion scintigraphy (MPS), are accurate for the detection of CAD, as well as having prognostic value for the prediction of cardiovascular events. Nevertheless, the diagnostic and prognostic value of these tests should be cost-effective and should lead to improved clinical outcome. We have reviewed the literature on the cost-effectiveness of MPS in different circumstances: (i) the diagnosis and management of CAD; (ii) comparison with exercise electrocardiography (ECG) and other imaging tests; (iii) as gatekeeper to invasive coronary angiography (ICA), (iv) the impact of appropriate use criteria; (v) acute chest pain, and (vi) screening of asymptomatic patients with type-2 diabetes. In total 57 reports were included. Although most non-invasive imaging tests are cost-effective compared with alternatives, the data conflict on which non-invasive strategy is the most cost-effective. Different definitions of cost-effectiveness further confound the subject. Computer simulations of clinical diagnosis and management are influenced by the assumptions made. For instance, diagnostic accuracy is often defined against an anatomical standard that is wrongly assumed to be perfect. Conflicting data arise most commonly from these incorrect or differing assumptions.

Myocardial perfusion SPECT 2015 in Germany. Results of the 7th survey.

AIM: The working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine presents the results of the 7th survey of myocardial perfusion SPECT (MPS) of the reporting year 2015. METHOD: 268 questionnaires (173 practices [PR], 67 hospitals [HO], 28 university hospitals [UH]) were evaluated. Results of the last survey from 2012 are set in squared brackets. RESULTS: MPS of 121 939 [105 941] patients were reported. 98 % [95 %] of all MPS were performed with Tc-99m radiopharmaceuticals and 2 % [5 %] with Tl-201. 78 % [79 %] of all patients were studied in PR, 14 % [15 %] in HO, and 8 % [6 %] in UH. A pharmacological stress test was performed in 43 % [39 %] (22 % [24 %] adenosine, 20 % [9 %] regadenoson, 1 % [6 %] dipyridamole or dobutamine). Attenuation correction was applied in 25 % [2009: 10 %] of MPS. Gated SPECT was performed in 78 % [70 %] of all rest MPS, in 80 % [73 %] of all stress and in 76 % [67 %] of all stress and rest MPS. 53 % [33 %] of all nuclear medicine departments performed MPS scoring by default, whereas 24 % [41 %] did not apply any quantification. 31 % [26 %] of all departments noticed an increase in their counted MPS and 29 % [29 %] no changes. Data from 89 departments which participated in all surveys showed an increase in MPS count of 11.1 % (PR: 12.2 %, HO: 4.8 %, UH: 18.4 %). 70 % [60 %] of the MPS were requested by ambulatory care cardiologists. CONCLUSION: The 2015 MPS survey reveals a high-grade adherence of routine MPS practice to current guidelines. The positive trend in MPS performance and number of MPS already observed in 2012 continues. Educational training remains necessary in the field of SPECT scoring.

Performance of cardiac cadmium-zinc-telluride gamma camera imaging in coronary artery disease: a review from the cardiovascular committee of the European Association of Nuclear Medicine (EANM).

The trade-off between resolution and count sensitivity dominates the performance of standard gamma cameras and dictates the need for relatively high doses of radioactivity of the used radiopharmaceuticals in order to limit image acquisition duration. The introduction of cadmium-zinc-telluride (CZT)-based cameras may overcome some of the limitations against conventional gamma cameras. CZT cameras used for the evaluation of myocardial perfusion have been shown to have a higher count sensitivity compared to conventional single photon emission computed tomography (SPECT) techniques. CZT image quality is further improved by the development of a dedicated three-dimensional iterative reconstruction algorithm, based on maximum likelihood expectation maximization (MLEM), which corrects for the loss in spatial resolution due to line response function of the collimator. All these innovations significantly reduce imaging time and result in a lower patient's radiation exposure compared with standard SPECT. To guide current and possible future users of the CZT technique for myocardial perfusion imaging, the Cardiovascular Committee of the European Association of Nuclear Medicine, starting from the experience of its members, has decided to examine the current literature regarding procedures and clinical data on CZT cameras. The committee hereby aims 1) to identify the main acquisitions protocols; 2) to evaluate the diagnostic and prognostic value of CZT derived myocardial perfusion, and finally 3) to determine the impact of CZT on radiation exposure.

Clinical use of quantitative cardiac perfusion PET: rationale, modalities and possible indications. Position paper of the Cardiovascular Committee of the European Association of Nuclear Medicine (EANM).

Until recently, PET was regarded as a luxurious way of performing myocardial perfusion scintigraphy, with excellent image quality and diagnostic capabilities that hardly justified the additional cost and procedural effort. Quantitative perfusion PET was considered a major improvement over standard qualitative imaging, because it allows the measurement of parameters not otherwise available, but for many years its use was confined to academic and research settings. In recent years, however, several factors have contributed to the renewal of interest in quantitative perfusion PET, which has become a much more readily accessible technique due to progress in hardware and the availability of dedicated and user-friendly platforms and programs. In spite of this evolution and of the growing evidence that quantitative perfusion PET can play a role in the clinical setting, there are not yet clear indications for its clinical use. Therefore, the Cardiovascular Committee of the European Association of Nuclear Medicine, starting from the experience of its members, decided to examine the current literature on quantitative perfusion PET to (1) evaluate the rationale for its clinical use, (2) identify the main methodological requirements, (3) identify the remaining technical difficulties, (4) define the most reliable interpretation criteria, and finally (5) tentatively delineate currently acceptable and possibly appropriate clinical indications. The present position paper must be considered as a starting point aiming to promote a wider use of quantitative perfusion PET and to encourage the conception and execution of the studies needed to definitely establish its role in clinical practice.

Nuclear cardiology practice and associated radiation doses in Europe: results of the IAEA Nuclear Cardiology Protocols Study (INCAPS) for the 27 European countries.

PURPOSE: Nuclear cardiology is widely used to diagnose coronary artery disease and to guide patient management, but data on current practices, radiation dose-related best practices, and radiation doses are scarce. To address these issues, the IAEA conducted a worldwide study of nuclear cardiology practice. We present the European subanalysis. METHODS: In March 2013, the IAEA invited laboratories across the world to document all SPECT and PET studies performed in one week. The data included age, gender, weight, radiopharmaceuticals, injected activities, camera type, positioning, hardware and software. Radiation effective dose was calculated for each patient. A quality score was defined for each laboratory as the number followed of eight predefined best practices with a bearing on radiation exposure (range of quality score 0 - 8). The participating European countries were assigned to regions (North, East, South, and West). Comparisons were performed between the four European regions and between Europe and the rest-of-the-world (RoW). RESULTS: Data on 2,381 European patients undergoing nuclear cardiology procedures in 102 laboratories in 27 countries were collected. A cardiac SPECT study was performed in 97.9 % of the patients, and a PET study in 2.1 %. The average effective dose of SPECT was 8.0 ± 3.4 mSv (RoW 11.4 ± 4.3 mSv; P < 0.001) and of PET was 2.6 ± 1.5 mSv (RoW 3.8 ± 2.5 mSv; P < 0.001). The mean effective doses of SPECT and PET differed between European regions (P < 0.001 and P = 0.002, respectively). The mean quality score was 6.2 ± 1.2, which was higher than the RoW score (5.0 ± 1.1; P < 0.001). Adherence to best practices did not differ significantly among the European regions (range 6 to 6.4; P = 0.73). Of the best practices, stress-only imaging and weight-adjusted dosing were the least commonly used. CONCLUSION: In Europe, the mean effective dose from nuclear cardiology is lower and the average quality score is higher than in the RoW. There is regional variation in effective dose in relation to the best practice quality score. A possible reason for the differences between Europe and the RoW could be the safety culture fostered by actions under the Euratom directives and the implementation of diagnostic reference levels. Stress-only imaging and weight-adjusted activity might be targets for optimization of European nuclear cardiology practice.

Position paper of the Cardiovascular Committee of the European Association of Nuclear Medicine (EANM) on PET imaging of atherosclerosis.

Cardiovascular diseases are the leading cause of death not only in Europe but also in the rest of the World. Preventive measures, however, often fail and cardiovascular disease may manifest as an acute coronary syndrome, stroke or even sudden death after years of silent progression. Thus, there is a considerable need for innovative diagnostic and therapeutic approaches to improve the quality of care and limit the burden of cardiovascular diseases. During the past 10 years, several retrospective and prospective clinical studies have been published using (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) to quantify inflammation in atherosclerotic plaques. However, the current variety of imaging protocols used for vascular (arterial) imaging with FDG PET considerably limits the ability to compare results between studies and to build large multicentre imaging registries. Based on the existing literature and the experience of the Members of the European Association of Nuclear Medicine (EANM) Cardiovascular Committee, the objective of this position paper was to propose optimized and standardized protocols for imaging and interpretation of PET scans in atherosclerosis. These recommendations do not, however, replace the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual study protocols used and the individual patient, in consultation with the patient and, where appropriate and necessary, the patient's guardian or carer. These recommendations suffer from the absence of conclusive evidence on many of the recommendations. Therefore, they are not intended and should not be used as "strict guidelines" but should, as already mentioned, provide a basis for standardized clinical atherosclerosis PET imaging protocols, which are subject to further and continuing evaluation and improvement. However, this EANM position paper might indeed be a first step towards "official" guidelines on atherosclerosis imaging with PET.

EANM procedural guidelines for radionuclide myocardial perfusion imaging with SPECT and SPECT/CT: 2015 revision.

Since the publication of the European Association of Nuclear Medicine (EANM) procedural guidelines for radionuclide myocardial perfusion imaging (MPI) in 2005, many small and some larger steps of progress have been made, improving MPI procedures. In this paper, the major changes from the updated 2015 procedural guidelines are highlighted, focusing on the important changes related to new instrumentation with improved image information and the possibility to reduce radiation exposure, which is further discussed in relation to the recent developments of new International Commission on Radiological Protection (ICRP) models. Introduction of the selective coronary vasodilator regadenoson and the use of coronary CT-contrast agents for hybrid imaging with SPECT/CT angiography are other important areas for nuclear cardiology that were not included in the previous guidelines. A large number of minor changes have been described in more detail in the fully revised version available at the EANM home page: http://eanm.org/publications/guidelines/2015_07_EANM_FINAL_myocardial_perfusion_guideline.pdf .