Table Of Content-
INTEGRATED NON INVASIVE
CARDIOVASCULAR IMAGING
A Guide for the Practitioner
Maurizio Dondi, Diana Paez, Paolo Raggi, Leslee J. Shaw, Mani Vannan
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INTEGRATED NON-INVASIVE
CARDIOVASCULAR IMAGING:
A GUIDE FOR THE PRACTITIONER
INTEGRATED NON-INVASIVE
CARDIOVASCULAR IMAGING:
A GUIDE FOR THE PRACTITIONER
M. DONDI, D. PAEZ, P. RAGGI, L.J. SHAW, M. VANNAN
INTERNATIONAL ATOMIC ENERGY AGENCY
VIENNA, 2021
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STI/PUB/1931
IAEA Library Cataloguing in Publication Data
Names: International Atomic Energy Agency.
Title: Integrated non-invasive cardiovascular imaging : a guide for the practitioner / International Atomic Energy Agency.
Description: Vienna : International Atomic Energy Agency, 2021. | Series: -, ISSN ; no. | Includes bibliographical references.
Identifiers: IAEAL 21-01421 | ISBN 978–92–0–133021–5 (paperback : alk. paper) | ISBN 978–92–0–133121–2 (pdf) | ISBN 978–92–0–
101621–8 (epub) | ISBN 978–92–0–101721–5 (mobipocket)
Subjects: LCSH: Heart — Imaging. | Nuclear medicine. | Radioisotopes in cardiology. | Single-photon emission computed tomography. |
Tomography, Emission.
Classification: UDC 616.12:616-073 | STI/PUB/1931
FOREWORD
Cardiovascular disease is a major contributor to premature morbidity and mortality worldwide, and
improving human health through early and effective diagnostic imaging is an effective means to positively
influence the health of a population. Through efforts within the IAEA, numerous initiatives have been
developed, or are underway, to promote quality medical imaging practices for the detection and guided
treatment of cardiovascular disease. These regional and global training and educational programmes
emphasize the importance of worldwide standards for instrumentation, protocols, appropriate use, and
high quality image interpretation and reporting practices.
The importance of addressing cardiovascular diseases and other non-communicable diseases is
recognized by United Nations organizations. Under United Nations Sustainable Development Goal 3, to
ensure healthy lives and to promote well being for everyone at all ages, the target is to reduce premature
non-communicable disease mortality by one third by 2030. The Global Action Plan, designed by the
World Health Organization, aims at preventing and controlling non-communicable diseases and offers a
roadmap and policy options. The aim is to prevent heart attacks and strokes and to achieve a 25% relative
reduction in premature mortality from non-communicable diseases by 2025.
Integrated cardiovascular imaging is an evolving concept. Recent advances in technology have
contributed to the development of new imaging modalities and the refinement of existing ones, leading to
major improvements in the accuracy of diagnosing cardiovascular and other diseases. While modality
centric knowledge and expertise have been the primary drivers of improvement in each modality, this has
also contributed to imagers working in silos, which has resulted in limited intermodality coordination and
collation of information relevant for patient care. Non-invasive imaging tools to diagnose and stratify risk
in cardiac disease and to guide its management include echocardiography, coronary computed tomography
angiography (CCTA), cardiac magnetic resonance (CMR) imaging and nuclear cardiology, using either
single photon emission computed tomography (SPECT) or positron emission tomography (PET) coupled
with computed tomography (CT). Each of these techniques has distinct characteristics that allow the
evaluation of details of the anatomy of the heart, its physiology or both. Depending on a patient’s
characteristics and the various potential clinical presentations, some of these techniques may be better
suited for some patients than other techniques, either for the initial work-up of a certain condition or as a
follow-up method to evaluate a condition already identified.
The IAEA plays an integral role in the development of clinical trial evidence and in the development
of guidance documents to synthesize available data into optimal strategies of care. Examples of IAEA
sponsored research can be found in recent publications.
The availability of technology is quite heterogeneous worldwide. Some countries have access to only
the most basic tools to evaluate the heart, such as electrocardiogram, exercise treadmill/bicycle test and
echocardiography. Other countries have various degrees of access to more advanced imaging
technologies, such as SPECT, CCTA, CMR imaging and PET–CT. It is advisable that physicians use all
the diagnostic potential of any techniques available, applying internationally accepted standard protocols,
and that the results be interpreted and acted upon appropriately.
This publication provides comprehensive guidance on the rationale for and implementation of
integrated cardiovascular imaging for practitioners. Imaging experts can embrace optimal strategies of
cardiovascular imaging to address an array of clinical conditions. By applying high quality evidence
published in peer reviewed literature, vast opportunities are available to improve the lives of patients at
risk of and diagnosed with cardiovascular disease, many of whom will benefit from the use of
cardiovascular imaging to guide optimal therapeutic decision making.
The IAEA is grateful to all who contributed to the drafting and review of this publication, in particular
P. Raggi (Canada), L.J. Shaw (United States of America) and M. Vannan (United States of America). The
IAEA acknowledges the contributions of the late Ravi Kashyap of the Division of Human Health. The
IAEA officers responsible for this publication were M. Dondi and D. Paez of the Division of Human
Health.
EDITORIAL NOTE
Although great care has been taken to maintain the accuracy of information contained in this publication, neither the IAEA nor
its Member States assume any responsibility for consequences which may arise from its use.
This publication does not address questions of responsibility, legal or otherwise, for acts or omissions on the part of any person.
Guidance provided here, describing good practices, represents expert opinion but does not constitute recommendations made on
the basis of a consensus of Member States.
The use of particular designations of countries or territories does not imply any judgement by the publisher, the IAEA, as to the
legal status of such countries or territories, of their authorities and institutions or of the delimitation of their boundaries.
The mention of names of specific companies or products (whether or not indicated as registered) does not imply any intention to
infringe proprietary rights, nor should it be construed as an endorsement or recommendation on the part of the IAEA.
The IAEA has no responsibility for the persistence or accuracy of URLs for external or third party Internet web sites referred to in
this book and does not guarantee that any content on such web sites is, or will remain, accurate or appropriate.
The authoritative versions of the publications are the hard copies issued and available as PDFs on
www.iaea.org/publications.To create the versions for e-readers, certain changes have been made,
including the movement of some figures and tables.
CONTENTS
CHAPTER 1: INTRODUCTION
1.1. Background
1.2. Objective
1.3. Scope
1.4. Structure
PART I: FUNDAMENTALS OF NON-INVASIVE CARDIAC IMAGING
CHAPTER 2: NUCLEAR CARDIOLOGY: SINGLE PHOTON EMISSION COMPUTED
TOMOGRAPHY
2.1. Hardware
2.2 Software
2.3. Hybrid SPECT–CT imaging systems
2.4. Safety
2.5. Key messages
References to Chapter 2
CHAPTER 3: NUCLEAR CARDIOLOGY: POSITRON EMISSION TOMOGRAPHY
3.1. Basic principles
3.2. Cardiac PET radiotracers
3.3. Imaging protocols
3.4. Key messages
References to Chapter 3
CHAPTER 4: ECHOCARDIOGRAPHY
4.1. Physics of echocardiography
4.2. 2-D and 3-D echocardiography
4.3. Doppler echocardiography
4.4. Speckle tracking echocardiography
4.5. Transthoracic and transoesophageal echocardiography
4.6. 3-D echocardiography
4.7. Contrast echocardiography
4.8. Key messages
References to Chapter 4
CHAPTER 5: CARDIAC MAGNETIC RESONANCE IMAGING
5.1. Basics of magnetic resonance imaging
5.2. Cardiac magnetic resonance
5.3. Blood flow evaluation using CMR
5.4. 4-D flow cardiac magnetic resonance
5.5. Safety considerations
5.6. Key messages
References to Chapter 5
CHAPTER 6: CARDIAC COMPUTED TOMOGRAPHY
6.1. Basic principles
6.2. Computed tomography hardware and software
6.3. Techniques
6.4. Advanced CCT techniques
6.5. Safety
6.6. Key messages
References to Chapter 6
PART II: CLINICAL APPLICATIONS
CHAPTER 7: INTEGRATED NON-INVASIVE CARDIOVASCULAR IMAGING IN ROUTINE
CLINICAL PRACTICE
7.1. Concept
7.2. Integrating the basics: ETT and echocardiography
7.3. Future of integrated cardiovascular imaging
7.4. Key messages
References to Chapter 7
CHAPTER 8: APPROPRIATE USE OF NON-INVASIVE CARDIAC IMAGING TECHNIQUES
8.1. Framework of appropriate imaging guidelines
8.2. Definition of appropriateness and application of guidelines
8.3. Future directions
8.4. Key messages
References to Chapter 8
CHAPTER 9: CURRENT EVIDENCE AND LESSONS LEARNED FROM RANDOMIZED
TRIALS IN CARDIOVASCULAR IMAGING
9.1. Hierarchy of clinical research evidence in cardiovascular imaging
9.2. Evidentiary standards for quality cardiovascular imaging
9.3. Lessons learned from observational data: Examples in nuclear cardiology
9.4. Defining comparative effectiveness
9.5. Examples of controlled clinical trials
9.6. Examples of comparative effectiveness trials
9.7. Therapeutic risk reduction: Guiding therapeutic decision making
9.8. Assimilating evidence into evaluation algorithms
9.9. Key messages
References to Chapter 9
CHAPTER 10: STABLE CORONARY ARTERY DISEASE
10.1. Clinical presentation
10.2. Risk prediction models and pre-test probability
10.3. Role of basic investigations
10.4. Role of non-invasive imaging in clinical decision making
10.5. Imaging algorithms based on clinical presentation
10.6. Conclusion
10.7. Key messages
References to Chapter 10
CHAPTER 11: ACUTE CORONARY SYNDROMES
11.1. Definition of acute coronary syndrome
11.2. Pathophysiology of acute coronary syndrome
11.3. Role of non-invasive imaging in acute coronary syndrome
11.4. Clinical utility of non-invasive imaging in acute coronary syndrome
11.5. Case based approach to imaging in acute coronary syndromes
11.6. Myocardial infarction with non-obstructive coronary arteries
11.7. Key messages
References to Chapter 11
CHAPTER 12: HEART FAILURE
12.1. Global and regional left ventricular function
12.2. Left ventricular size and shape
12.3. Myocardial morphology and function
12.4. Myocardial ischaemia or viability
12.5. Left atrium and right ventricle
12.6. Valve disease
12.7. Key messages
References to Chapter 12
CHAPTER 13: CARDIOMYOPATHIES
13.1. Hypertrophic cardiomyopathy
13.2. Dilated cardiomyopathy
13.3. Restrictive cardiomyopathy
13.4. Specific cardiomyopathies
13.5. Classification of cardiomyopathies according to left ventricular systolic or diastolic
dysfunction
13.6. Key messages
References to Chapter 13
CHAPTER 14: PERICARDIAL DISEASES
14.1. Acute pericarditis
14.2. Cardiac tamponade
14.3. Constrictive pericarditis
14.4. Key messages
References to Chapter 14
