ABC | Volume 114, Nº2, February 2020

Update Update of the Brazilian Guideline on Nuclear Cardiology – 2020 Arq Bras Cardiol. 2020; 114(2):325-429 Content 1. Introduction ......................................................................................330 2. Addendum to the ISCHEMIA Study ...............................................330 3. The Application of Nuclear Medicine Techniques to Justify Financial Resources Available for Attending Cardiology Patients in Brazil ......................................................................................................331 3.1. Introduction ......................................................................................331 3.2. Cost-Effectiveness in Comparison with Cardiac Catheterization ........331 3.3. Cost-Effectiveness of Myocardial Perfusion Scintigraphy in Relation to Coronary Angiotomography .....................................................................332 4. Indications for Myocardial Perfusion Scintigraphy ....................332 5. Myocardial Perfusion Scintigraphy Methods – Types of Cardiovascular Stress ..........................................................................335 5.1. Radiopharmaceuticals Used to Perform Myocardial Perfusion Scintigraphy .............................................................................................335 5.2. Myocardial Perfusion Scintigraphy with Tomography Imaging (SPECT) ....................................................................................................337 5.3. Myocardial Perfusion Scintigraphy with Tomographic Images Synchronized with Electrocardiogram (Gated-SPECT) ...............................337 5.4. Cardiovascular Stress .......................................................................338 5.5. Image Generation and Perfusion Defects in Myocardial Scintigraphy with Radioisotopes ..................................................................................344 5.6. Possible Scintigraphy Imaging Results, Using Qualitative, Semi- quantitative, and Quantitative Analyses ...................................................344 6. Current Utilization of Myocardial Perfusion and Ventricular Function Studies with Radiopharmaceuticals as Part of The Medical Decision-Making Process ....................................................348 6.1. The Application of Bayes’ Theorem to Analysis of Myocardial Perfusion Images with Radiopharmaceuticals .........................................................349 6.2. Value of the Diagnosis-Prognosis Binomial to Integrated Assessment of Perfusion Images .....................................................................................351 6.3. Radiopharmaceuticals for Performance of Myocardial Perfusion Scintigraphy and Image Generation and Perfusion Defects .....................351 7. Evaluation of Patients with Potential Acute Coronary Syndrome – Algorithms in the Chest Pain Unit .................................................353 7.1. Introduction ......................................................................................353 7.2. Goals for Evaluating Acute Chest Pain and Participation of Non-invasive Methods in Assessing ACS .......................................................................354 8. Positron Emission Tomography in Cardiology ............................357 8.1. Introduction ......................................................................................357 8.2. Basic Principles of Positron Emission and Main Indications ................357 8.3. Radioactive Tracers for Use in Basic Principles of Positron Emission and Main Indications ...............................................................................358 8.4. Use of PET for Assessment of Myocardial Ischemia ..........................358 8.5. Patient Preparation, Types of Stress, and Dosimetry .........................360 9. Integrating Diagnostic Modalities in Cardiology – Tutorial Cases .....................................................................................................361 9.1. Introduction ......................................................................................361 9.2. Integrating Physiology (Exercise Testing and Nuclear Cardiology) and Anatomy (Calcium Score and Coronary Angiotomography) ......................361 9.3. Practical Examples of Integration of Modalities ................................364 10. Evaluation of Myocardial Viability Via Myocardial Perfusion Scintigraphy ..........................................................................................389 10.1. Introduction ....................................................................................389 10.2. Morphology .....................................................................................390 10.3. Evaluation of Viable Myocardium ....................................................390 10.4. Physiopathology and Definitions .....................................................390 10.5. The Most Frequently Used Protocols ...............................................391 10.6. Positron Emission Tomography .......................................................392 10.7. Additional Information Based on Evidence within the Medical Decision-making process for Patients with Congestive Heart Failure, Decreased Left Ventricular Ejection Fraction, and Viable Myocardium .....393 11. New Technologies and Future Perspectives for Nuclear Cardiology in Studying Ischemic Heart Disease .............................394 12. Strategies for Reducing Exposure to Radiation .......................395 12.1. Reducing Radiation Using New Technologies, Image Quality, and Reliability of Findings ...............................................................................396 13. Evaluation of Cardiac Sympathetic Activity by Scintigraphy with 123 I-MIBG .......................................................................................398 13.1. Introduction ....................................................................................398 13.2. Cardiac Scintigraphy with 123 I-MIBG ................................................398 13.3. Aplicações Clínicas da Cintilografia Cardíaca com 123 I-MIBG ...........399 13.3.1. Heart Failure ...............................................................................401 13.3.2. Ventricular Arrhythmia ...............................................................401 13.3.3. Cardiotoxicity Due to Chemotherapy .........................................402 13.3.4. Cardiac Autonomic Dysfunction in Diabetes Mellitus ...............403 13.3.5 Cardiac Transplant .......................................................................403 13.3.6. Takotsubo Syndrome ..................................................................403 13.4. Final Considerations .......................................................................404 14. New Applications of Nuclear Cardiology ...................................404 14.1. Introduction ....................................................................................404 14.2. Endocarditis ....................................................................................404 14.3. Myocarditis .....................................................................................406 14.4. Pericarditis .....................................................................................407 14.5. Cardiac Sarcoidosis ........................................................................407 14.6. Cardiac Amyloidosis .......................................................................409 14.7. Final Considerations .......................................................................410 References ............................................................................................412 329