Stress/injection protocols for myocardial scintigraphy with 99Tcm-sestamibi compared with 201Tl: implications of...

Stress/injection protocols developed for myocardial perfusion imaging with 201Tl may not be optimal for 99Tcm-sestamibi (MIBI), an agent with lower myocardial extraction and higher abdominal uptake; prolongation of exercise after radiotracer injection might improve these relative drawbacks of MIBI. We compared the kinetics of MIBI and 201Tl by acquiring dynamic planar images for 5-7 min after a bolus injection (n = 180 studies) with stress performed by supine bicycle exercise alone, intravenous dipyridamole or combined stress. Routine or prolonged protocols involved continuation of exercise for 1 or 2.5 min respectively after tracer appearance in the heart. Subsequently, the perfusion images obtained were categorized as normal or showing significant defects. Myocardial uptake of MIBI, normalized for injected dose, body weight and camera sensitivity, was only 40% of that for 201Tl; there were no differences based on test mode or scan result for either perfusion tracer. During the second minute after injection, the cavity/myocardial ratios, an index of blood pool activity, were elevated with MIBI by 25% when compared with 201Tl (P < 0.001). During the third minute, cavity activity was again higher with MIBI, but only in those subjects with abnormal scans. The prolonged exercise phase did not prevent progressive accumulation in the abdomen, but did allow cavity levels to decline before termination of exercise. The prolonged protocol may ensure that myocardial uptake of MIBI is completed during peak blood flow, and therefore is recommended for stress with exercise or with dipyridamole and exercise in combination.