Is the PPI responsible for that inferior MI?
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Division of Cardiology, Hartford Hospital, Hartford, CT
Received Jun 12, 2019; accepted Jun 12, 2019 doi:10.1007/s12350-019-01795-9
See related article, https://doi.org/10.10 07/s12350-019-01733-9
Gastrointestinal (GI) radiotracer uptake, including stomach, liver, and intestinal counts, in patients undergoing single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has the potential to degrade image quality and adversely impact interpretation. Extracardiac localization may cause increases in adjacent myocardial segments by Compton scatter or decreased counts via ramp filter artifact. The occurrences of these artifacts plague our nuclear laboratories and provide ample opportunities for improvement in imaging technique. Several factors have been identified that contribute to increased gastrointestinal uptake including supine positioning, stomach contents, timing of image acquisition, pharmacological stressors, radiotracer, and specific medications. Currently, laboratories mitigate the impact of extracardiac uptake by withholding food and oral fluids, timing injection and scanning appropriately, rescanning if inadequate images, and utilizing attenuation correction. In this issue of the Journal of Nuclear Cardiology, Singh et al propose to consider proton pump inhibitors (PPI) as a medication which increases stomach wall tracer uptake.1 GI tracer uptake, along with patient motion and soft tissue attenuation, are a daily hinderance to quality SPECT perfusion imaging. The combination of these imaging artifacts is likely responsible for the majority of preventable imaging errors and helps contribute to the less than perfect accuracy of perfusion imaging. The assessment of these artifacts is a foundational
Reprint requests: W. Lane Duvall, MD, Division of Cardiology, Hartford Hospital, Hartford, CT, USA; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2019 American Society of Nuclear Cardiology.
component of the evaluation of every perfusion study by the technologist and physician, and in the case of GI tracer uptake and motion artifact, can be mitigated by repeat imaging when identified. All too often in this day of over-burdened health care staff, these basics of perfusion imaging techniques can be overlooked and compromises made to image quality. While any efforts to reduce the interpretation errors from imaging artifacts such as the work reported in this issue of the Journal are welcome, we must not forget that quality perfusion imaging begins and ends with the laboratory staff. Prior work on the specific subject of stomach wall tracer uptake is quite limited and often small in regards to the sample size. The only large study on the subject by Gholamrezanezhad et al in 2006 described 1056 consecutive outpatients and found only 1.9% of patients had gastric wall hyperactivity.2 This low prevalence of stomach wall uptake is in contrast to the higher prevalence (8-36%) seen in the current study in the Journal. Two relatively small prospective observational studies com
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