Journal of Nuclear Cardiology

, Volume 1, Supplement 5, pp S99–S108 | Cite as

Choosing a thallium-201 or technetium 99m sestamibi imaging protocol

  • James E. Udelson


During the past decade progress in the field of myocardial perfusion imaging has resulted in a myriad of choices for perfusion imaging protocols, including choices in types of stressor, imaging modality, perfusion tracer, method of analysis, and a wide range of choices of imaging protocols. This review will examine this latter aspect in the context of choices of perfusion tracers that are now available for wide use. Manipulations of thallium protocols have revolved primarily around optimizing identification of stress defect reversibility and regional myocardial viability. The high image quality and long retention time afforded by the technetium-labeled agents allow the potential for streamlining imaging protocols to maximize efficiency and cost-effectiveness, such as performing stress only imaging in a subset of patients and performing simultaneous assessment of perfusion and function.

Key Words

thallium 201 sestamibi imaging protocols 


  1. 1.
    Rozanski A, Berman DS. The efficacy of cardiovascular nuclear medicine exercise studies. Sem Nucl Med 1987;27:104–20.CrossRefGoogle Scholar
  2. 2.
    Brown K. Prognostic value of thallium-201 myocardial perfusion imaging: a diagnostic tool comes of age. Circulation 1991;83:363–81.PubMedGoogle Scholar
  3. 3.
    Maddahi J, Kiat H, Van Train K, et al. Myocardial perfusion imaging with technetium-99m sestamibi SPECT in the evaluation of coronary artery disease. Am J Cardiol 1990;66:55E-62E.PubMedCrossRefGoogle Scholar
  4. 4.
    Stratmann H, Williams G, Wittry M, Miller D. Prognostic value of exercise testing with technetium-99m sestamibi in>500 patients with stable chest pain. Circulation 1993;88:I-486.Google Scholar
  5. 5.
    Raiker K, Sinusas A, Zaret B, Wackers F. One-year prognosis of patients with normal Tc99m-sestamibi stress imaging. Circulation 1993;88:I-486.Google Scholar
  6. 6.
    Berman D, Palmas W, Kiat H, Cabico J, Cohen I, Friedman J. Incremental prognostic value of exercise dual isotope (rest T1-201/stress Tc-99m sestamibi) myocardial perfusion SPECT. Circulation 1993;88:I-486.Google Scholar
  7. 7.
    Udelson JE, Coleman PS, Metherall J, et al. Predicting recovery of severe regional ventricular dysfunction: comparison of resting scintigraphy with 201 T1 and 99m Tc-sestamibi. Circulation 1994;89:2552–61.PubMedGoogle Scholar
  8. 8.
    Dilsizian V, Arrighi JA, Diodati JG, et al. Myocardial viability in patients with chronic coronary artery disease: comparison of 99m Tc-sestamibi with thallium 201 reinjection and [18F] fluorodeoxyglucose. Circulation 1994;89:578–87.PubMedGoogle Scholar
  9. 9.
    Marzullo P, Parodi O, Reisenhofer B, et al. Value of rest thallium-201/technetium-99m sestamibi scans and dobutamine echocardiography for detecting myocardial viability. Am J Cardiol 1993;71:166–72.PubMedCrossRefGoogle Scholar
  10. 10.
    Pohost G, Zir LM, Moore RH, McKusick KA, Guiney TE, Beller GA. Differentiation of transiently ischemic from infarcted myocardium by serial imaging after a single dose of thallium 201. Circulation 1977;55:294–302.PubMedGoogle Scholar
  11. 11.
    Blood D, McCarthy D, Siacca R, Cannon P. Comparison of single-dose and double-dose thallium-201 myocardial perfusion scintigraphy for the detection of coronary artery disease and prior myocardial infarction. Circulation 1981;58:777–88.Google Scholar
  12. 12.
    Gibson R, Watson D, Taylor G, et al. Prospective assessment of regional myocardial perfusion before and after coronary revascularization surgery by quantitative thallium-201 scintigraphy. J Am Coll Cardiol 1983;1:804–15.PubMedGoogle Scholar
  13. 13.
    Brunken R, Schwaiger M, Grover-McKay M, Phelps M, Tillisch J, Schelbert H. Positron emission tomography detects tissue metabolic activity in myocardial segments with persistent thallium perfusion defects. J Am Coll Cardiol 1987;10:557–67.PubMedGoogle Scholar
  14. 14.
    Kiat H, Berman D, Madahi J, et al. Late reversibility of tomographic myocardial thallium-201 defects: an accurate marker of myocardial viability. J Am Coll Cardiol 1988;12: 1456–63.PubMedCrossRefGoogle Scholar
  15. 15.
    Dilsizian V, Rocco T, Freedman N, Leon M, Bonow R. Enhanced detection of ischemic but viable myocardium by the reinjection of thallium after stress-redistribution imaging. N Engl J Med 1990;323:141–6.PubMedGoogle Scholar
  16. 16.
    Rocco T, Dilsizian V, McKusick K, Fischman A, Boucher C, Strauss H. Comparison of thallium redistribution with rest “reinjection” imaging for detection of viable myocardium. Am J Cardiol 1990;66:158–63.PubMedCrossRefGoogle Scholar
  17. 17.
    Ohtani H, Tamaki N, Yonekura Y, et al. Value of thallium-201 reinjection after delayed SPECT imaging for predicting reversible ischemia after coronary artery bypass grafting. Am J Cardiol 1990;66:394–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Bonow R, Dilsizian V, Cuocolo A, Bacharach S. Identification of viable myocardium in patients with chronic coronary artery disease and left ventricular dysfunction: comparison of thallium scintigraphy with reinjection and PET imaging with 18F-fluorodeoxyglucose. Circulation 1991;83:26–37.PubMedGoogle Scholar
  19. 19.
    Lemleck H, Heo J, Nguyen T, Iskandrian A. How important is the issue of myocardial viability clinically [Abstract]? J Am Coll Cardiol 1991;17:77A.Google Scholar
  20. 20.
    Iskandrian A, Hakki A, Kane S, et al. Rest and redistribution thallium-201 myocardial scintigraphy to predict improvement in left ventricular function after coronary arterial bypass grafting. Am J Cardiol 1983;51:1312–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Mori T, Minamiji K, Kurogane H, Ogawa K, Yoshida Y. Rest-injected thallium-201 imaging for assessing viability of severe asynergic regions. J Nucl Med 1991;32:1718–24.PubMedGoogle Scholar
  22. 22.
    Ragosta M, Beller G, Watson D, et al. Quantitative planar rest-redistribution T1201 imaging in detection of myocardial viability and prediction of improvement in left ventricular function after coronary bypass surgery in patients with severely depressed left ventricular function. Circulation 1993;87:1630.PubMedGoogle Scholar
  23. 23.
    Dilsizian V, Perrone-Filardi P, Arrighi J, et al. Concordance and discordance between stress-redistribution-reinjection and rest-redistribution thallium imaging for assessing viable myocardium. Circulation 1993;88:941.PubMedGoogle Scholar
  24. 24.
    Dilsizian V, Bonow R. Differential uptake and apparent T1201 washout after thallium reinjection: options regarding early redistribution imaging before reinjection or late redistribution imaging after reinjection. Circulation 1992;85:1032–8.PubMedGoogle Scholar
  25. 25.
    Leavitt J, Better N, Syravanh C, Mannting G, Tow D, Rocco R. Thallium reinjection immediately after stress imaging offers comparable information to delayed reinjection. Circulation 1993;88:I-200.Google Scholar
  26. 26.
    Dilsizian V, Bonow R, Quyyumi A, Smeltzer W, Bacharach S. Is early thallium reinjection after post-exercise imaging a satisfactory method to detect defect reversibility? Circulation 1993;88:I-199.Google Scholar
  27. 27.
    Okada R, Glover D, Gaffney T, Williams S. Myocardial kinetics of technetium 99m-hexakis-2-methoxy-2-methylpropyl-isonitrile. Circulation 1988;77:491–8.PubMedGoogle Scholar
  28. 28.
    Taillefer R, Gagnon A, Laflamme L, Grégoire J, Léveillé J, Phaneuf D-C. Same day injection of Tc-99m methoxy isobutyl isonitrile (hexamibi) for myocardial tomographic imaging: comparison between rest-stress and stress-rest injection sequences. Eur J Nucl Med 1989;15:113–7.PubMedGoogle Scholar
  29. 29.
    Heo J, Kegel J, Iskandrian A, Cave V, Iskandrian B. Comparison of same-day protocols using technetium-99m-sestamibi myocardial imaging. J Nucl Med 1992;33:186–91.PubMedGoogle Scholar
  30. 30.
    Iskandrian A, Heo J, Kong B, Lyons E, Marsch S. Use of technetium-99m isonitrile (RP-30A) in assessing left ventricular perfusion and function at rest and during exercise in coronary artery disease, and comparison with coronary arteriography and exercise thallium-201 SPECT imaging. Am J Cardiol 1989;64:270–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Bonow RD, Kent KM, Rosing DR, et al. Exercise-induced ischemia in mildly symptomatic patients with coronary artery disease and preserved left ventricular function: identification of subgroups at risk of death during medical therapy. N Engl J Med 1984;311:1339–45.PubMedGoogle Scholar
  32. 32.
    Pryor D, Harrel FE, Lee KL, et al. Prognostic indicators from radionuclide angiography in medically treated patients with coronary artery disease. Am J Cardiol 1984;53:18–22.PubMedCrossRefGoogle Scholar
  33. 33.
    Lee K, Pryor DB, Pieperk S, et al. Prognostic value of radionuclide angiography in medically treated patients with coronary artery disease: a comparison with clinical and catheterization variables. Circulation, 1990;82:1705–17.PubMedGoogle Scholar
  34. 34.
    Kahn J, McGhie I, Faber TL, et al. Assessment of myocardial viability with technetium-99m 2-methoxyisobutyl isonitrile (MIBI) and gated tomography in patients with coronary artery disease [Abstract]. J Am Coll Cardiol 1989;13:31A.Google Scholar
  35. 35.
    Faber T, Kahn J, Akers M, Corbett J. Automatic calculation of LV volumes and EF from gated RP-30 tomograms [Abstract]. J Nucl Med 1988;29:805.Google Scholar
  36. 36.
    DePuey E, Nichols K, Dobrinsky C, Slowikowski J. Left ventricular ejection fractions from gated tomographic and from Tc-99m-sestamibi SPECT. J Nucl Med 1992;33:927–9.Google Scholar
  37. 37.
    Williams K, Taillon L, Draho J. Gated tomographic ejection fraction using Tc-99m-sestamibi myocardial perfusion image inversion: comparison with first-pass radionuclide angiography [Abstract]. J Am Coll Cardiol 1993;21:250A.Google Scholar
  38. 38.
    Snapper H, Shea N, Konstam M, et al. Combined analysis of regional wall motion and perfusion using gated SPECT sestamibi imaging: prediction of stress defect reversibility. Circulation 1993;88:I-582.Google Scholar
  39. 39.
    Chua T, Kiat H, Germano G, et al. Gated technetium 99m sestamibi for simultaneous assessment of stress myocardial perfusion, postexercise regional ventricular function and myocardial viability: correlation with echocardiography and rest thallium-201 scintigraphy. J Am Coll Cardiol 1994;23:1107–14.PubMedCrossRefGoogle Scholar
  40. 40.
    Wackers F, Berman D, Maddahi J, et al. Technetium-99m hexakis 2-methoxyisobutyl isonitrile: human biodistribution, dosimetry, safety and preliminary comparison to thallium-201 for myocardial perfusion imaging. J Nucl Med 1989;30:301–11.PubMedGoogle Scholar
  41. 41.
    Taillefer R, Lambert R, Bisson G, Benjamin C, Phaneuf D. Comparison between early (15 minutes) and delayed (60 minutes) myocardial 99mTc-sestamibi SPECT imaging in detection of coronary artery disease [Abstract]. J Nucl Med 1992;33:855.Google Scholar
  42. 42.
    Taillefer R, Primeau M, Costi P, Lambert R, Léveillé J, Latour Y. Technetium-99m-sestamibi myocardial perfusion imaging in detection of coronary artery disease: comparison between initial (1-hour) and delayed (3-hour) postexercise images. J Nucl Med 1991;32:1961–5.PubMedGoogle Scholar
  43. 43.
    Sinusas A, White M, Perez V, Mattera J, Zaret B, Wackers F. Delaying postexercise Tc99m-sestamibi imaging may result in underestimation of ischemia. Circulation 1992;86:I-505.Google Scholar
  44. 44.
    Berman D, Kiat H, Friedman J, et al. Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computed tomography: a clinical validation study. J Am Coll Cardiol 1993;22:1455–64.PubMedGoogle Scholar
  45. 45.
    Lucas J, Agarwal P, Pounds T, et al. Comparison of diagnostic accuracy of dual radionuclide (T1-201 and Tc-99m isonitrile) with same day Tc-99m isonitrile stress/T1-201 rest perfusion scintigraphy [Abstract]. J Nucl Med 1993;34:62P.Google Scholar
  46. 46.
    Stobbe D, Milne N, Sanford I, Karlsberg R, Krane M, Lyons K. Sensitivity of dual isotope SPECT myocardial perfusion imaging for detection of specific atherosclerotic lesions: a comparison to angiography [Abstract]. J Nucl Med 1993;34:65P.Google Scholar

Copyright information

© American Society of Nuclear Cardiology 1994

Authors and Affiliations

  • James E. Udelson
    • 1
    • 2
  1. 1.Department of MedicineTufts University School of Medicine and New England Medical Center HospitalsBoston
  2. 2.Division of Nuclear Medicine, Department of RadiologyTufts University School of Medicine and New England Medical Center HospitalsBoston

Personalised recommendations