Available online 16 September 2023

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This paper describes the evolution of nuclear cardiology techniques in the setting of acute coronary syndromes. Since the 1970s, the contribution of nuclear cardiology has been fundamental in delineating the physiopathology and diagnosis of acute myocardial infarction, when electrocardiogram (ECG) did not provide the diagnosis and when cardiac enzyme assessments were at a very early stage. In this clinical situation, at that time the role of pyrophosphate scintigraphy and antimyosin antibodies was important in ensuring diagnostic precision. However, these methods showed limitations and were abandoned in the late 80s and early 90s when therapeutic applications such as thrombolytic therapy, and primary-and rescue-percutaneous coronary intervention (PCI) were introduced. Beginning in the mid-80s, the introduction and widespread use of perfusion tracers such as 99mTc labelled compounds and technological advances such as SPECT, allowed to assess the efficacy of thrombolysis and early revascularization, as well as to assess in depth myocardial salvage. Currently, perfusion SPECT, especially using fast imaging techniques and dedicated cardiac SPECT with solid-state detectors, allows a quick confirmation or exclusion of acute coronary syndromes, particularly in low-to-intermediate likelihood of coronary artery disease (CAD), especially when there are absolute or relative contraindications to the use of coronary computed tomographic angiography (CCTA).

Section snippetsBackground

The evolution of clinical practice is linked to the improvement of physiopathological knowledge; enhancement of diagnostic potential particularly of imaging techniques; and the introduction of effective pharmacological, interventional, and surgical therapies that can significantly change prognosis and life expectancy of patients with ischemic heart disease. The use of artificial intelligence models would be able to integrate all knowledge about the individual's history and condition in order to

Diagnosis of Acute Myocardial Infarction With Bone Seeking Agents

The first reports on the use of infarct avid tracers in animal models were published in the 70’s.3 In dogs, 99m-Tc Pyrophosphate (PyP) imaging acquire with the first SPECT prototypes, enabled to diagnose and assess the infarct site and extent.4 Soon these techniques were applied to the diagnosis of acute infarction in humans5 and represented a diagnostic cornerstone for Coronary Care Units (CCU) worldwide. Investigators at Massachusetts General Hospital experimented in the late 1970s with the

Perfusion Tracers: 201-thallium (201-Tl)

Wackers et al.12 set the standard of acute myocardial infarct in a study published 47 years ago. These authors noted a sensitivity of 94% of 201-Tl scintigraphy in the identification of myocardial necrosis, if the tracer was injected within 6 hours of symptom onset, but with progressively lower sensitivity with later injections. They also found that the size of the perfusion defect area decreased over time in a number of patients, until it disappeared in some, especially in subjects with non-Q

Perfusion Tracers: 99m-Tc Sestamibi, 99mTc-Tetrofosmin

Technetium-labelled perfusion tracers immediately gained wide acceptance due to their flexibility of use, lower costs, and 24-hour availability. Due to their minimal wash-out after administration, these tracers allow delayed imaging after injection while maintaining myocardial distribution reflecting perfusion at the time of administration. The first tracer in this family is 99mTc sestamibi (2-methoxyisobutyl isonitrile), a lipophilic cation that is sequestered within mitochondria by the

The use of MPI in the Emergency Department

The use of SPECT with 99m-Tc Sestamibi in the ED to ascertain or exclude an ACS was proposed in the early 1990s by Varetto et al.24 They evaluated consecutive patients admitted to the ED for the evaluation of chest pain of suspected cardiac origin (chest pain of >30 minutes duration, arising within 12 hours after presentation to the ED, unexplained by non cardiac causes, and with non diagnostic ECG). Thirty of 64 patients showed perfusion defects on admission. Of these, 13 developed myocardial

MPI or CCTA?

In the diagnosis of acute infarction in subjects with chest pain and equivocal ECG, nuclear medicine procedures and coronary computed tomography angiography (CCTA) could be used. The latter, has entered overwhelmingly into the diagnostic work-up of the patient with suspected acute coronary syndrome. Several studies have proven the effectiveness of CCTA in the evaluation of patients admitted to the ED for chest pain.

In a multicenter prospective study,32 1370 subjects were enrolled: 908 in the

Positron Emission Tomography

Recently, there has been a growing interest in exploring the role of positron emission tomography/computed tomography (PET/CT) myocardial perfusion imaging in the evaluation of patients with acute chest pain.41, 42, 43 This imaging technique offers several advantages that can provide valuable insights into the underlying causes of chest pain and guide appropriate management strategies. PET/MPI allows for the quantification of myocardial ischemia and infarction, assessment of coronary calcium,

Conclusions

In conclusion, the use of nuclear cardiology procedures, and specifically MPI, has contributed extensively to the understanding the pathophysiology of acute coronary syndromes and deepening its knowledge. It still retains an important role in the diagnostic and prognostic framing of ACS, especially in subjects with unclear presentation in emergency departments. The introduction of CCTA has certainly modified the first line approach to ACS. The choice of the most appropriate diagnostic procedure

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References (43)DH. SpodickTransmural vs nontransmural infarction

Circulation

(1980)

S Thanavaro et al.In-hospital prognosis of patients with first nontransmural and transmural infarctions

Circulation

(1980)

LM Buja et al.Morphologic correlates of technetium-99m stannous pyrophosphate imaging of acute myocardial infarcts in dogs

Circulation

(1975)

JW Keyes et al.Myocardial infarct quantification in the dog by single photon emission computed tomography

Circulation

(1978)

BA Khaw et al.Myocardial infarct imaging of antibodies to canine cardiac myosin with indium-111-diethylenetriamine pentaacetic acid

Science

(1980 11)

LL Johnson et al.Measurement of infarct size and percentage myocardium infarcted in a dog preparation with single photon-emission computed tomography, thallium-201, and indium 111-monoclonal antimyosin Fab

Circulation

(1987)

Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI)

Lancet

(1986)

S Dorbala et al.Addendum to ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI expert consensus recommendations for multimodality imaging in cardiac amyloidosis: Part 1 of 2-evidence base and standardized methods of imaging

J Nucl Cardiol

(2021 Aug)

FJ Wackers et al.Value and limitations of thallium-201 scintigraphy in the acute phase of myocardial infarction

N Engl J Med

(1976)

M Galli et al.Spontaneous delayed recovery of perfusion and contraction after the first 5 weeks after anterior infarction. Evidence for the presence of hibernating myocardium in the infarcted area

Circulation

(1994)

S Tamaki et al.Improved detection of myocardial infarction by emission computed tomography with thallium-201. Relation to infarct size

Br Heart J

(1984)

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