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Nuclear Cardiology: which gold standard for single photon emission tomography?

An article from the e-journal of the ESC Council for Cardiology Practice

SPECT shows a high correlation with coronary stenosis, more proportional to coronary flow reserve than anatomy. SPECT also provides relevant data concerning scar, volumes and regional and global ventricular functions from a single study.

Non-Invasive Imaging

In medicine, gold standard techniques are rare, may be quite invasive or expensive and more currently accepted than perfect. In some cases the gold standard is unknown, and a result is plotted against that of another more accepted method. Cardiac imaging techniques are used for estimating different parameters such as flow and function, and single photon emission tomography (SPECT) is a nuclear cardiology multipurpose technique used in several cardiovascular fields. Each field has different standards, and SPECT is frequently used as a standard itself. This paper will compare the current accuracy of SPECT with respect to coronary anatomy, starting from significant lesions up to intermediate coronary stenoses and “normal” vessels.


The principle behind SPECT is impairment between myocardial supply and demand. Since flow tracers have a good relationship with myocardial blood flow up to moderate hyperemia, ischemia or simply flow misdistribution result in a reversible perfusion defect.

Significant coronary lesions

Since its introduction in 1976, taking as a standard a coronary lesion > 70%, myocardial perfusion scintigraphy has been characterized by a continuous increase in sensitivity up to 85-90% after the introduction of Gated SPECT.
In the era of planar imaging, specificity also increased from qualitative to quantitative Thallium 201 analysis. However, SPECT resulted in a loss of specificity mostly due to a high incidence of false positives caused by artefacts in image reconstruction or soft tissue attenuation. In the last decade, the diffusion of Technetium tracers with higher photons flux resulted in a continuous increase in specificity up to 70-75% or even >80% with Gated SPECT (1). Thus, using significant coronary lesions as standard, SPECT has a high accuracy among stress imaging techniques. If we shift the standard from significant angiographic lesions to PET quantification of regional blood flow, SPECT continues to identify most segments with a reduced coronary flow reserve (2). However, a minority of PET areas with intermediate reduction of hyperemic coronary blood flow are not detected by SPECT. The good overall accuracy of SPECT is associated with several added values such as the possibility of separating single and multivessel diseases, identifying high risk patients after myocardial infarction and detect tissue viability.

Intermediate lesions

These kind of lesions are rather complex because their angiographic degree of stenosis does not predict the occurrence of stress ischemia, and thus additional information is needed for clinical decision making. There are several studies demonstrating that even quantitative angiography does not predict ischemia while Doppler measurements of flow reserve are able to differentiate between “innocent” or “culprit” lesions (3). In these vessels, SPECT is in close agreement with fractional flow reserve rather than with quantitative angiography, and this is true for normal as well as for previously infarcted segments (4). Thus, beyond invasive Doppler measurements, SPECT is a technique that shows a good correlation with flow reserve, and thus may be clinically used to assess whether an intermediate lesion should be treated or not by percutaneous coronary interventions or by-pass surgery.

“Normal” vessels

Recent observations obtained by intravascular ultrasounds showed that SPECT reversible defects may occur even in areas perfused by “normal” coronary arteries with unrecognised atherosclerotic plaques (5). These plaques may be not detected through angiography, but may result in flow misdistribution as evidenced by a reduced coronary flow reserve. Once again, the angiographic standard gives imperfect results.


Beyond improving specificity by reducing the number of attenuation artefacts, Gated SPECT has its own standards in terms of volume and regional wall motion. Several studies demonstrated that Gated SPECT accurately measures end diastolic and end systolic volumes providing a quantitative evaluation of regional wall motion and thickening at the same time (6). Finally, the combined flow/function analysis provides additional diagnostic and prognostic power to SPECT.



SPECT has been compared with different standards. Significant lesions are detected with high accuracy in the majority of patients, and intermediate lesions with a positive scan are undoubtedly to be considered as flow limiting stenoses. For these reasons, in the absence of a detectable coronary artery disease, a positive SPECT deserves more attention than the generic label of false positive scan, although different conditions such as diabetes, hypertrophy and cardiomyopathies that may reduce “angiographic” specifity mostly through microvascular mechanisms should also be considered.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.


1) Beller GA, Zaret BL. Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease. Circulation 2000; 101 :1465-1478.

2) Yoshinaga K, Katoh C, Noriyasu K, et al. Reduction of coronary flow reserve in areas with and without ischemia on stress perfusion imaging in patients with coronary artery disease: A study using oxygen 15-labeled water PET. J Nucl Cardiol 2003; 10: 275-283.

3) Heller LI, Cates C, Popma J, et al. Intracoronary Doppler assessment of moderate coronary artery disease. Circulation 1997; 96: 484-490.

4) De Bruyne B, Pijls NHJ, Bartunek J, et al. Fractional flow reserve in patients with prior myocardial infarction. Circulation 2001; 104: 157-167.

5) Verna E, Ceriani L, Giovanella L, et al. “False-Positive” myocardial perfusion scintigraphy findings in patients with angiographically normal coronary arteries: insights from intravascular sonography studies. J Nucl Med 2000; 41 :1935-1940.

6) Stollfuss JC, Haas F, Matsunari I, et al. Regional myocardial wall thickening and global ejection fraction in patients with low angiographic left ventricular ejection fraction assessed by visual and quantitative resting ECG-gated 99mtc-tetrofosmin single-photon emission tomography and magnetic resonance imaging. Eur J Nucl Med 1998; 25 :522-530.

Notes to editor

Dr Marzullo P.
Pisa, Italy
Past Chairman of the ESC Working Group on Nuclear Cardiology

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.