ABC | Volume 114, Nº2, February 2020

Update Update of the Brazilian Guideline on Nuclear Cardiology – 2020 Arq Bras Cardiol. 2020; 114(2):325-429 Table 5 – Indication criteria for myocardial perfusion scintigraphy for risk stratification and prognostic assessment of patients with proven stable coronary artery disease and/or prior exams Asymptomatic patients or patients with stable symptoms – previously “normal” stress imaging exams Score Intermediate/high risk (ATP III) – stress imaging exam ≥ 2 years prior 6 Asymptomatic patients or patients with stable symptoms – CCA or abnormal imaging exams, without prior CABG CAD on CCA or “abnormal” stress imaging exam (exam performed > 2 years prior) 5 CAD on CCA or “abnormal” stress imaging exam (exam performed < 2 years prior) 3 Previously “unclear,” “contradictory,” or “borderline” non-invasive assessment – obstructive CAD as initial concern 8 New, recent, or progressive symptoms Abnormal CCA or abnormal stress imaging exam 9 Normal CCA or normal stress imaging exam 6 Coronary cineangiography (invasive or non-invasive) Coronary stenosis or anatomical abnormality whose significance is unclear 9 ACS: acute coronary syndrome; ATP III: Adult Treatment Panel, from the program for detection, evaluation, and treatment of high cholesterol in adults; CAD: coronary artery disease; CCA: coronary cineangiography; CABG: myocardial revascularization surgery. Table 6 – Indication criteria for myocardial perfusion scintigraphy in patients with acute chest pain or post-acute coronary syndrome Assessment of patients with acute chest pain Score Resting image only Possible ACS – ECG without ischemic alterations or LBBB or pacemaker; low-risk TIMI score; borderline, minimally elevated, or negative troponin 8 Possible ACS – ECG without ischemic alterations or LBBB or pacemaker; high-risk TIMI score; borderline, minimally elevated, or negative troponin 7 / 8 Possible ACS – ECG without ischemic alterations or LBBB or pacemaker; negative initial troponin. Recent (up to 2 hours) or evolving chest pain 7 Assessment of post-ACS patients (infarction with or without elevated ST segment) Stable, post-AMI patients, with ST segment elevation, for assessment of ischemia; cardiac catheterization not performed 8 Stable, post-AMI patients, without ST segment elevation, for assessment of ischemia; cardiac catheterization not performed 9 ACS: acute coronary syndrome; AMI: acute myocardial infarction; CAD: coronary artery disease; ECG: 12-lead electrocardiogram; LBBB: left bundle branch block. Table 7 – Indication criteria for myocardial perfusion scintigraphy for pre-operative assessment of non-cardiac surgeries Pre-operative assessment of non-cardiac surgeries Score Low-risk surgery 1 Intermediate-risk surgery or vascular surgery Functional capacity greater than or equal to 4 METs 1 Intermediate-risk surgery or vascular surgery Functional capacity unknown or less than 4 METs No clinical risk factors 1 Intermediate-risk surgery Functional capacity unknown or less than 4 METs One or more clinical risk factors 7 Vascular surgery Functional capacity unknown or less than 4 METs One or more clinical risk factors 8 MET: metabolic equivalent. whether MPS will be necessary. In patients with functional capacity estimated at greater than or equal to 4 METs, without cardiac symptoms, regardless of clinical or surgical risk, non- invasive assessment of myocardial ischemia is generally not recommended. However, for patients with low functional capacity and elevated clinical/surgical risks, there is an indication to performMPS under pharmacological stress. The following are considered clinical risks: history of ischemic heart disease, congestive heart failure (CHF), cerebrovascular disease, diabetes mellitus (DM), and renal insufficiency (creatinine > 2.0 mg/dl). In the absence of these risk factors, regardless of functional capacity, surgery may be performed without complementary functional exams (Table 7). In patients with accentuated left ventricular dysfunction who are eligible for myocardial revascularization, assessment of myocardial viability may aid selection of patients who will benefit from this treatment (Table 8). MPS is, therefore, an appropriate indication in diverse clinical manifestations of ischemic heart disease, from acute manifestations in the emergency room to diagnostic investigation of stable patients, aiding in therapeutic decision making through various tools which make it possible to define disease severity, as well as in pre-operative assessment in specific situations and in defining the benefits of revascularization for patients with significant myocardial 334