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Overcoming Challenges

Overcoming Challenges

Potential Nuclear Lab Challenges and the Patient Experience

Minimizing the Burden of Canceled Tests

Efficiency is often important in a busy nuclear cardiology lab. Anticipating challenges that can disrupt the daily workflow and implementing strategies to address the underlying issues can help avoid unnecessary interruptions.

Inability to Adequately Exercise

Exercise stress testing is the gold standard and provides diagnostic and prognostic information. Adequate exercise requires patients to reach ≥85% of the maximum predicted heart rate (MPHR) and ≥5 metabolic equivalents (METs). Exercise tests should be symptom-limited and not stopped because adequate exercise is achieved.1 Exercise testing may need to be aborted if the patient experiences symptoms such as moderate-to-severe chest pain, excessive shortness of breath, or fatigue.1 Preparing patients for both exercise and pharmacologic stress testing may help avoid canceled or rescheduled tests and improve the patient experience.

Use the calculator below to help determine 85% of a patient’s MPHR2:

85% OF MAXIMUM
PREDICTED HEART RATE
(beats per minute)
=
(220 -  ) x 0.85

MPHR calculator developed by Astellas.

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Caffeine Consumption

For patients who are unable to adequately exercise and need pharmacologic stress, abstaining from xanthine-containing substances such as caffeine and theophylline is important for achieving accurate results.3 Counseling patients on what to avoid before the pharmacologic stress test can help prevent the need for cancellation or rescheduling. Below, please find a nonexhaustive list of things patients should avoid if undergoing a pharmacologic stress test.

Drinks to avoid4
  • Coffee (brewed, instant, iced, decaf)
  • Tea (brewed, instant, iced, decaf)
  • Soda pop (including “caffeine-free”)
  • Energy drinks
  • Chocolate milk (or chocolate-flavored drinks, including nutritional drinks)
  • Hot cocoa
  • Drinks containing guarana
Foods to avoid4
  • Brownies
  • Chocolate pudding, cakes, and candies
  • Energy bars
  • Foods containing guarana
Some medicines to avoid
Over-the-counter drugs with caffeine
Prescription drugs with caffeine
Anacin®
(aspirin, caffeine)5
Cafergot®
(ergotamine tartrate, caffeine)9
Excedrin®
(acetaminophen, aspirin, caffeine)6
Esgic®
(acetaminophen, butalbital, caffeine)10
Vivarin®
(caffeine)7
Fioricet®
(acetaminophen, butalbital, caffeine)11
NoDoz®
(caffeine)8
Fiorinal®
(butalbital, aspirin, caffeine)12
 
Some medicines to avoid
Prescription drugs with dipyridamole (do not take for 48 hours)
Prescription drugs with theophylline
Aggrenox®
(aspirin, dipyridamole)13
Elixophyllin®
(theophylline)15
Persantine®
(dipyridamole)14
Theo-24®
(theophylline)16
 
 
 
 
Patient Test Prep Checklist

This 2-page resource provides your patients with a take-home checklist that can help them prepare for their stress test. It includes a partial list of things your patient should NOT eat or drink prior to their test, as well as some medications to avoid.

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Artifacts

Technical and patient-related issues that can cause artifacts may arise during stress myocardial perfusion imaging (MPI). Artifacts can lead to false-positive results.17,18

Patient Motion

When patients are uncomfortable during image acquisition, they are more likely to create motion artifacts and compromise data integrity, as stated in an article from the Journal of Nuclear Medicine Technology. Patients may have discomfort due to illness, back pain, lack of flexibility, fatigue, or anxiety.17

Patient Heart Imaging Test Guide

This guide helps educate patients about what to expect during a nuclear stress test and how to properly prepare before the test.

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Technical Issues

Periodic inspection and recalibration of MPI cameras, as recommended by the Intersocietal Accreditation Commission (IAC), is necessary.18 Always refer to the manufacturer’s recommendations for periodic assessment of scintillation cameras.

Testing in Patients With Comorbidities

Certain patient populations pose unique challenges when imaging for coronary artery disease (CAD). For example, MPI testing in patients with left bundle-branch block (LBBB), implantable cardiac pacemakers, chronic kidney disease (CKD), or asthma or chronic obstructive pulmonary disease (COPD) requires special considerations for achieving quality imaging results.3,4,19,20

Lab Efficiencies

Nonphysician Exercise Stress Testing

With the increasing focus on delivering efficient, cost-conscious imaging, trained nonphysician providers may conduct exercise stress tests under a physician's supervision according to American Hospital Association (AHA) guidelines.23 The degree of supervision needed should be determined by the physician based on the patient’s clinical status. This can help contain costs while maintaining quality of care.23

Stress-Only Imaging

American Society of Nuclear Cardiology (ASNC) guidelines recommend performing a stress test first and, if the stress test results are normal, canceling the rest test. This minimizes radiation exposure during a 1-day study. In obese patients for whom a 2-day study is appropriate, ASNC guidelines recommend performing the stress test first, using attenuation correction if available, and cancel the rest study if the stress test results are normal.24

References+

1. Henzlova MJ, Cerqueira MD, Hansen CL, Taillefer R, Yao SS. ASNC imaging guidelines for nuclear cardiology procedures: stress protocols and tracers. J Nucl Cardiol 2009. http://www.asnc.org/files/Stress%20Protocols%20and%20Tracers%202009.pdf. Accessed 05-10-2018. 2. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001;37:153-6. 3. DePuey EG, Mahmarian JJ, Miller TD, et al. Patient-centered imaging. J Nucl Cardiol 2012;19(2):1-31. Erratum in: J Nucl Cardiol 2012;19(3):633. 4. Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures: stress, protocols, and tracers. J Nucl Cardiol 2016;23(3):606-39. Erratum in: J Nucl Cardiol 2016;23(3):640-2. 5. Anacin [package insert]. Tarrytown, NY: Insight Pharmaceuticals, LLC; 2019. 6. Excedrin [package insert]. Warren, NJ: Novartis Consumer Health, Inc.; 2014. 7. Vivarin [package insert]. Atlanta, GA: Meda Consumer Healthcare Inc.; 2014. 8. NoDoz [package insert]. Cedar Rapids, IA: Lil’ Drug Store Products, Inc.; 2019. 9. Cafergot [package insert]. Princeton, NJ: Sandoz Inc.; 2012. 10. Esgic [package insert]. Atlanta, GA: MIKART, LLC.; 2019. 11. Fioricet [package insert]. Irvine, CA: Nexgen Pharma, Inc.; 2016. 12. Fiorinal [package insert]. Parsippany, NJ: Actavis Pharma, Inc.; 2014. 13. Aggrenox [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; 2018. 14. Persantine [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; 2018. 15. Elixophyllin [package insert]. Bryan, OH: SUN Pharmaceutical Industries, Inc.; 2014. 16. Theo-24 [package insert]. Caguas, PR: Neolpharma, Inc.; 2017. 17. Wheat JM, Currie GM. Incidence and characterization of patient motion in myocardial perfusion SPECT: Part 1. J Nucl Med Technol 2004;32(2):60-5. 18. Intersocietal Accreditation Commission. The IAC standards and guidelines for nuclear/PET accreditation (09-15-2016). https://www.intersocietal.org/nuclear/standards/IACNuclearPETStandards2016.pdf. Accessed 04-01-2019. 19. Thompson S, James M, Wiebe N, et al. Cause of death in patients with reduced kidney function. J Am Soc Nephrol 2015;26(10):2504-11. 20. Okwuosa T, Williams KA. Coronary artery disease and nuclear imaging in renal failure. J Nucl Cardiol. 2006;13:150-5. 21. Udelson JE, Dilsizian V, Bonow RO. Nuclear cardiology. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald’s Heart Disease. 11th ed. Philadelphia, PA: Elsevier Saunders, 2019:261-300. 22. Kidney Disease Improving Global Outcomes. 2012 clinical practice guideline for the evaluation and management of chronic kidney disease (01-2013). https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf. Accessed 05-03-2019. 23. Myers J, Forman DE, Balady GJ, et al. Supervision of exercise testing by nonphysicians. Circulation 2014;130(12):1014-27. 24. Cerqueira MD, Allman KC, Ficaro EP, et al. Recommendations for reducing radiation exposure in myocardial perfusion imaging. J Nucl Cardiol 2010;17(4):709-18.