Nuklearmedizinische Funktionsdiagnostik in der Kardiologie

Herz-Kreislauf-Erkrankungen sind die häufigste Todesursache in Deutschland. In Kombination ermöglichen klinische Kriterien und geeignete Bildgebungsverfahren eine präzise Diagnosefindung und führen zur Einleitung einer passenden Therapie. Nuklearmedizinische bildgebende Verfahren sind Funktionsuntersuchungen, die biologische Prozesse sichtbar machen. Dieser Beitrag bietet eine Übersicht aktueller nuklearmedizinischer Bildgebungsmethoden für kardiale Fragestellungen.

Abstract

Cardiac nuclear medicine comprises various diagnostic techniques using radiopharmaceuticals for functional imaging in vivo. This article provides an overview of current clinical use of cardiac imaging in nuclear medicine in Germany: Myocardial perfusion imaging using SPECT is a well-established noninvasive tool to semi-quantitatively measure left ventricular myocardial perfusion. Ischemia and chronic myocardial scars can be idenified with a high diagnostic accuracy. Gated SPECT enables measuring left ventricular function. With new dedicated solid-state camera systems examinations have become faster and better while radiation exposure has been minimized. These new camera systems allow quantitative calculations of myocardial blood flow, which will further improve diagnostic accuracy.

For patients with severe chronic coronary artery disease and myocardial dysfunction analyzing myocardial viability is crucial for guiding therpeutic decisions. For detection of hibernating myocardium and its differentiation from scar tissue, two nuclear cardiac methods are combined: Rest myocardial perfusion imaging detects perfusion defects and cardiac 18F-FDG-PET/CT detects glucose metabolism in the hypoperfused area. As long as glucose metabolism is intact therapeutic interventions can be beneficial.

In general 18F-FDG-PET/CT allows visualization and quantification of celluar glucose metabolism in oncologic and inflammatory processes. For analysis of cardiac inflammation (e. g. endocarditis or sarcoidosis) a no-carb and high-protein diet is needed at leat 24 hours prior to imaging in order to suppress the physiologic myocardial glucose metabolism. Then, specific inflammatory tracer uptake can be assessed.

Cardiac amyloidosis is a rare but dangerous condition. With a specific amyloidosis scintigraphy (bone scintigraphy), cardiac ATTR-amyloidosis can be diagnosed with high accuracy. A potenitally harmful myocardial biopsy often is not needed any more and specific therapy can be initiated.

In summary, diagnostic methods in cardiac nuclear medicine non-invasively allow visualization and function analysis of biological processes and are essential for diagnosis finding and therapy guidance. The continuous advancement of diagnostic tools makes nuclear cardiology a highly relevant and interesting field.

Schlüsselwörter

molekulare Funktionsbildgebung - PET - SPECT - koronare Herzerkrankung - kardiale Entzündung

Key words

molecular imaging - PET - SPECT - coronary artery disease - cardiac inflammation

Publication History

Article published online:
25 April 2022

• Literatur

• 1 Knuuti J, Bengel F, Bax JJ. et al. Risks and benefits of cardiac imaging: an analysis of risks related to imaging for coronary artery disease. Eur Heart J 2014; 35: 633-638 DOI: 10.1093/eurheartj/eht512.
• 2 IQTIG. Qualitätsreport 2020. 2020: 70-71 https://iqtig.org/veroeffentlichungen/qualitaetsreport . Stand: 10.01.2022
• 3 Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Nationale VersorgungsLeitlinie (NVL) Chronische KHK. 2019 5. Auflage. Version 1. https://www.leitlinien.de/themen/khk . Stand: 10.01.2022
• 4 Knuuti J, Wijns W, Saraste A. et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41: 407-477 DOI: 10.1093/eurheartj/ehz425.
• 5 Lindner O, Burchert W, Buechel R. et al. Myocardial Perfusion SPECT 2018 in Germany: Results of the 8th Survey. Nuklearmedizin 2019; 58: 425-433 DOI: 10.1055/a-1023-3960.
• 6 Silverman MG, Blaha MJ, Krumholz HM. et al. Impact of coronary artery calcium on coronary heart disease events in individuals at the extremes of traditional risk factor burden: the Multi-Ethnic Study of Atherosclerosis. Eur Heart J 2014; 35: 2232-2241 DOI: 10.1093/eurheartj/eht508.
• 7 Lindner O, Bengel F, Burchert W. et al. [Myokard-Perfusions-SPECT. Myocardial perfusion SPECT – Update S1 guideline]. Nuklearmedizin 2017; 56: 115-123 DOI: 10.3413/Nukmed-2017040001.
• 8 Hachamovitch R, Berman DS, Shaw LJ. et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 1998; 97: 535-543 DOI: 10.1161/01.cir.97.6.535.
• 9 Hachamovitch R, Rozanski A, Hayes SW. et al. Predicting therapeutic benefit from myocardial revascularization procedures: are measurements of both resting left ventricular ejection fraction and stress-induced myocardial ischemia necessary?. J Nucl Cardiol 2006; 13: 768-778 DOI: 10.1016/j.nuclcard.2006.08.017.
• 10 Hachamovitch R, Hayes SW, Friedman JD. et al. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 2003; 107: 2900-2907 DOI: 10.1161/01.CIR.0000072790.23090.41.
• 11 Maron DJ, Hochman JS, Reynolds HR. et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020; 382: 1395-1407 DOI: 10.1056/NEJMoa1915922.
• 12 Spertus JA, Jones PG, Maron DJ. et al. Health-Status Outcomes with Invasive or Conservative Care in Coronary Disease. N Engl J Med 2020; 382: 1408-1419 DOI: 10.1056/NEJMoa1916370.
• 13 Gibbons RJ. Myocardial Ischemia in the Management of Chronic Coronary Artery Disease: Past and Present. Circ Cardiovasc Imaging 2021; 14: e011615 DOI: 10.1161/CIRCIMAGING.120.011615.
• 14 Hachamovitch R, Soman P. ISCHEMIA Trial: Are We Still Fighting the Last War?. Circ Cardiovasc Imaging 2021; 14: e012319 DOI: 10.1161/CIRCIMAGING.120.012319.
• 15 Bax JJ, Delgado V. Myocardial viability as integral part of the diagnostic and therapeutic approach to ischemic heart failure. J Nucl Cardiol 2015; 22: 229-245 DOI: 10.1007/s12350-015-0096-5.
• 16 Panza JA, Chrzanowski L, Bonow RO. Myocardial Viability Assessment Before Surgical Revascularization in Ischemic Cardiomyopathy: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78: 1068-1077 DOI: 10.1016/j.jacc.2021.07.004.
• 17 Slart RHJA, Glaudemans AWJM, Gheysens O. et al. Procedural recommendations of cardiac PET/CT imaging: standardization in inflammatory-, infective-, infiltrative-, and innervation (4Is)-related cardiovascular diseases: a joint collaboration of the EACVI and the EANM. Eur J Nucl Med Mol Imaging 2021; 48: 1016-1039 DOI: 10.1007/s00259-020-05066-5.
• 18 Habib G, Lancellotti P, Antunes MJ. et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36: 3075-3128 DOI: 10.1093/eurheartj/ehv319.
• 19 Chareonthaitawee P, Beanlands RS, Chen W. et al. Joint SNMMI–ASNC Expert Consensus Document on the Role of 18F-FDG PET/CT in Cardiac Sarcoid Detection and Therapy Monitoring. J Nucl Med 2017; 58: 1341-1353 DOI: 10.2967/jnumed.117.196287.
• 20 Maurer MS, Elliott P, Comenzo R. et al. Addressing Common Questions Encountered in the Diagnosis and Management of Cardiac Amyloidosis. Circulation 2017; 135: 1357-1377 DOI: 10.1161/CIRCULATIONAHA.116.024438.
• 21 Grogan M, Scott CG, Kyle RA. et al. Natural History of Wild-Type Transthyretin Cardiac Amyloidosis and Risk Stratification Using a Novel Staging System. J Am Coll Cardiol 2016; 68: 1014-1020 DOI: 10.1016/j.jacc.2016.06.033.
• 22 Seferovic PM, Ponikowski P, Anker SD. et al. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21: 1169-1186 DOI: 10.1002/ejhf.1531.
• 23 Perugini E, Guidalotti PL, Salvi F. et al. Noninvasive etiologic diagnosis of cardiac amyloidosis using 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy. J Am Coll Cardiol 2005; 46: 1076-1084 DOI: 10.1016/j.jacc.2005.05.073.
• 24 Gillmore JD, Maurer MS, Falk RH. et al. Nonbiopsy Diagnosis of Cardiac Transthyretin Amyloidosis. Circulation 2016; 133: 2404-2412 DOI: 10.1161/CIRCULATIONAHA.116.021612.
• 25 Yilmaz A, Bauersachs J, Kindermann I. et al. Diagnostik und Therapie der kardialen Amyloidose. Kardiologe 2019; 13: 264-291 DOI: 10.1007/s12181-019-00344-5.
• 26 Birnie DH, Nery PB, Ha AC. et al. Cardiac Sarcoidosis. J Am Coll Cardiol 2016; 68: 411-421 DOI: 10.1016/j.jacc.2016.03.605.
• 27 Castano A, Haq M, Narotsky DL. et al. Multicenter Study of Planar Technetium 99m Pyrophosphate Cardiac Imaging: Predicting Survival for Patients With ATTR Cardiac Amyloidosis. JAMA Cardiol 2016; 1: 880-889 DOI: 10.1001/jamacardio.2016.2839.