Review Article
Utility of nuclear cardiovascular imaging in the cardiac intensive care unit

https://doi.org/10.1007/s12350-021-02665-zGet rights and content

Abstract

The contemporary Cardiac Intensive Care Unit (CICU) has evolved into a complex unit that admits a heterogeneous mix of patients with a wide range of acute cardiovascular diseases often complicated by multi-organ failure. Although electrocardiography (ECG) and echocardiography are well-established as first-line diagnostic modalities for assessing patients in the CICU, nuclear cardiology imaging has emerged as a useful adjunctive diagnostic modality. The versatility, safety and accuracy of nuclear imaging (e.g., perfusion, metabolism, inflammation) for the assessment of patient with coronary artery disease, ventricular arrhythmias, infiltrative cardiomyopathies, infective endocarditis and inflammatory aortopathies has been proven useful and now often incorporated into the best practices for the management of critically ill cardiac patients. Thus, clinicians must familiarize themselves with the value and current and future applications of nuclear imaging in the management of the cardiac patient in the CICU.

Introduction

The contemporary Cardiac Intensive Care Unit (CICU) has evolved into a complex unit that admits a heterogeneous mix of patients with a wide range of acute cardiovascular diseases often complicated by multi-organ failure.1 Although electrocardiography (ECG) and echocardiography are well-established as the first-line diagnostic modalities for assessing patients in the CICU, nuclear cardiology imaging when appropriate 2,3 has emerged as a useful adjunctive diagnostic modality in the management of these complex patients. The diagnostic versatility of nuclear imaging, along with relatively short acquisition time, minimal need for patient cooperation, independence of renal and hepatic function, and the lack of interference with cardiac devices make this a useful and safe imaging modality in the CICU. (Figure 1) 4, 5, 6, 7, 8 In addition to the utility of nuclear myocardial perfusion and viability imaging in the ischemic heart, advances in molecular imaging have enabled clinicians to accurately diagnose and promptly initiate therapies, often without the need for cardiac biopsy, for inflammatory and infiltrative cardiomyopathies such as cardiac amyloidosis and sarcoidosis. These are now considered common clinical entities that enter the differential diagnosis of patients in the CICU. The utility of such advances has extended to the management of patients with suspected infective endocarditis and inflammatory aortopathies. The following is a review on the modern uses of nuclear cardiology imaging in the management of critically ill patients admitted to the CICU.

Section snippets

Nuclear myocardial perfusion, metabolic imaging and ischemic heart disease in the CICU

Ischemic heart disease (IHD) is highly prevalent in the CICU with a wide range of clinical presentations including acute coronary syndromes (ACS), ventricular tachycardia (VT) and cardiogenic shock, or a combination of them.9 The decision to revascularize patients with multi-vessel coronary artery disease (CAD) including total occlusions, and severely depressed LVEF is often challenging. In such scenarios, the following questions commonly arise: (1) Is the current presentation driven by

Nuclear imaging in the management of ventricular tachycardia in the CICU

Ventricular tachycardia (VT) is frequently encountered in the CICU, often complicating heart failure exacerbations, cardiogenic shock or acute coronary syndromes. Although IHD is the most common cause of VT, the causes and underlying VT mechanism are diverse.33 Monomorphic VT is typically associated to structural heart disease with underlying myocardial scarring, while polymorphic VT and ventricular fibrillation (VF) are rather associated to myocardial ischemia, myocarditis, profound

Nuclear imaging in the evaluation of advanced atrioventricular block in the CICU

High-degree atrioventricular block (AVB) when associated to hemodynamic instability or unstable escape rhythm mandates admission to the CICU with the implantation of a temporary pacemaker.39 The causes of high-degree AVB are diverse including progression of degenerative conduction disease, acute coronary syndrome, myocarditis, sarcoidosis, medication-induced among others.40 Beyond the implantation of temporary pacemaker if clinically indicated, the ultimate management of these patients in the

Nuclear imaging in the assessment of cardiomyopathy of unknown etiology in the CICU

A large proportion of patients are admitted to the CICU for medical optimization of cardiogenic shock or low output state. The identification of reversible causes and drivers of decompensation is of utmost relevance in order to guide short- and long-term therapeutics. In this setting, MPI is particularly helpful as ischemia is often the precipitating factor. On other occasions, it can help determine when patients have reached end stage ischemic cardiomyopathy with large burden of scar and thus

Nuclear imaging in the management of infective endocarditis and aortitis in the CICU

Infective endocarditis (IE) is commonly encountered in the CICU, particularly when there is associated valve destruction with hemodynamic decompensation or septic shock. IE is a clinical diagnosis guided by the Duke criteria,42 nevertheless often the diagnosis remains elusive or non-definitive after the initial clinical evaluation.

Cardiac/whole body F18-FDG PET/CT imaging following the same dietary preparation as for sarcoid protocol is of adjunctive diagnostic and prognostic value in the

Conclusion

As the contemporary CICU continues to evolve into more complex units caring for sicker patients, the role of nuclear cardiovascular imaging will continue to grow. The versatility, safety and accuracy of radionuclide imaging of cardiovascular perfusion, function, metabolism, and inflammation uniquely elucidate pathophysiologic mechanisms of cardiac disease and direct timely, appropriate and effective medical, revascularization and immunosuppressive therapies to optimize patient-centered care and

Disclosures

Aldo L. Schenone, Erika Hutt, Paul Cremer, and Wael A. Jaber have nothing to disclose.

References (50)

  • Muñoz BonoJ et al.

    Eficacia y seguridad de la implantación de marcapasos transvenosos transitorios en una unidad de cuidados intensivos

    Med Intensiva.

    (2011)
  • KusumotoFM et al.

    2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the heart rhyth

    J Am Coll Cardiol

    (2019)
  • HyafilF et al.

    Nuclear imaging for patients with a suspicion of infective endocarditis: Be part of the team!

    J Nucl Cardiol.

    (2017)
  • MorrowDA et al.

    Evolution of critical care cardiology: Transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: A scientific statement from the American Heart Association

    Circulation

    (2012)
  • SchindlerTH et al.

    Appropriate use criteria for PET myocardial perfusion imaging

    J Nucl Med

    (2020)
  • Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate use criteria for cardiac...
  • DilsizianV et al.

    PET myocardial perfusion and metabolism clinical imaging

    J Nucl Cardiol

    (2009)
  • ChareonthaitaweeP 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)
  • MahmoodM et al.

    Meta-analysis of 18F-FDG PET/CT in the diagnosis of infective endocarditis

    J Nucl Cardiol.

    (2017)
  • SlartRHJA et al.

    FDG-PET/CT(A) imaging in large vessel vasculitis and polymyalgia rheumatica: Joint procedural recommendation of the EANM, SNMMI, and the PET Interest Group (PIG), and endorsed by the ASNC

    Eur J Nucl Med Mol Imaging.

    (2018)
  • Sousa-UvaM et al.

    2018 ESC/EACTS Guidelines on myocardial revascularization

    Eur J Cardiol Thorac Surg.

    (2019)
  • BatemanTM et al.

    American Society of Nuclear Cardiology and Society of Nuclear Medicine and Molecular Imaging joint position statement on the clinical indications for myocardial perfusion PET

    J Nucl Med

    (2016)
  • HenzlovaMJ et al.

    ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers

    J Nucl Cardiol

    (2016)
  • DilsizianV et al.

    ASNC imaging guidelines/SNMMI procedure standard for positron emission tomography (PET) nuclear cardiology procedures

    J Nucl Cardiol.

    (2016)
  • HachamovitchR et al.

    Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy

    Eur Heart J

    (2011)

    • The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarises the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on SpringerLink.com.

    The authors have also provided an audio summary of the article, which is available to download as ESM, or to listen to via the JNC/ASNC Podcast.

    All editorial decisions for this article, including selection of reviewers and the final decision, were made by guest editor Saurabh Malhotra, MD, MPH.

    View full text
    Copyright © 2023 American Society of Nuclear Cardiology. Published by ELSEVIER INC. All rights reserved. Published by Mosby, Inc. All rights reserved.