Current Techniques and Practices for Myocardial Stress Testing—A Comparative Survey between Malta and International Nuclear Medicine Centres


Objectives: The study compared cardiac scintigraphy stress scanning practices applied in a National Maltese Nuclear Medicine centre and in international centres. This was achieved through the design of an online survey which investigated participant knowledge of stress testing, and current procedural practice. Methods: An online survey comprising 12 questions was prepared using Survey Monkey. Professional Nuclear Medicine groups such as the Medical-Physics-Engineering community and Virtual Radiopharmacy were targeted. Access to the survey remained open for eight months during which a periodic reminder was sent to optimise the response rate. Forty-three members responded from across Europe and Australasia. Chi-square tests and comparisons between multiple responses using IBM SPSS 20 were used to evaluate the results. Information related to Maltese practice was collated separately for review and comparative purposes. Results: The online survey participants comprised United Kingdom [72%], other European countries [18%] and Australasia [9%]. The majority of respondents [n = 39] reported pharmacological stress testing as being performed either alone or in conjunction with exercise stress testing as the preferred option. Most participants [60%] were aware of local stress test protocols but had limited knowledge in relation to guidelines designed for cases where patients were not suitable for pharmacological stress testing. Conclusion: The survey provided information about procedures within participating centres for scintigraphic cardiac stress scanning. Differences were identified with regards to the preferred radiopharmaceutical tracers and procedural protocols. Further investigation of examination techniques is warranted, with the aim of increasing standardisation of protocol compliance and the application of more suitable practice.

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Borg Grima, K. , O’Leary, D. , Bezzina, P. and Rainford, L. (2014) Current Techniques and Practices for Myocardial Stress Testing—A Comparative Survey between Malta and International Nuclear Medicine Centres. Open Journal of Clinical Diagnostics, 4, 217-226. doi: 10.4236/ojcd.2014.44031.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Dondi, M., Kashyap, R., Paez, D., Pascual, T., Zaknun, J., Bastos, F.M., et al. (2011) Trends in Nuclear Medicine in Developing Countries. Journal of Nuclear Medicine, 52, 16S-23S.
[2] Borg, A. (2013) Almost 60% Decrease in Heart Disease Deaths in Malta since 1980. The Malta Independent Online.
[3] (2012) Medical Imaging Department Statistics. MID, Mater Dei Hospital, Msida.
[4] Lele, V.R. and Soman, P. (2009) Nuclear Cardiology in India and the Developing World: Opportunities...and Challenges! Journal of Nuclear Cardiology, 16, 348-350.
[5] Duatti, A. (2008) Promoting Nuclear Medicine in Developing Countries through IAEA Coordinated Research Projects: Technical Reports Series 458 and 459. The Quarterly Journal of Nuclear Medicine and Molecular Imaging, 52, 209-211.
[6] Gholamrezanezhad, A., Mirpour, S. and Behbahani, A.A. (2010) Nuclear Medicine in Developing Countries: Perspective from Iran. Journal of Nuclear Medicine, 51, 14N-19N, 22N.
[7] NUMDAB [NUclear Medicine DAtaBase] (2003) International Atomic Agency.
[8] Goethals, L.R., Santos, I., Caveliers, V., Paulo, A., De Geeter, F., Lurdes, P.G., et al. (2011) Rapid Hepatic Clearance of 99mTc-TMEOP: A New Candidate for Myocardial Perfusion Imaging. Contrast Media & Molecular Imaging, 6, 178-188.
[9] Kelly, J.D., Forster, A.M., Higley, B., Archer, C.M., Booker, F.S., Canning, L.R., et al. (1993) Technetium-99m-Tetrofosmin as a New Radiopharmaceutical for Myocardial Perfusion Imaging. Journal of Nuclear Medicine, 34, 222-227.
[10] Chamarthy, M. and Travin, M.I. (2010) Altered Biodistribution and Incidental Findings on Myocardial Perfusion Imaging. Seminars in Nuclear Medicine, 40, 257-270.
[11] Gallardo, F.G., Gómez, M.V. and Terol, I. (2011) Prognostic Value of Normal Myocardial Perfusion Scintigraphy with 201Tl in Post-Acute Myocardial Infarction. Revista Espanola de Medicina Nuclear [English Edition], 30, 83-87.
[12] Berman, D.S., Kang, X., Tamarappoo, B., Wolak, A., Hayes, S.W., Nakazato, R., et al. (2009) Stress Thallium-201/Rest Technetium-99m Sequential Dual Isotope High-Speed Myocardial Perfusion Imaging. JACC: Cardiovascular Imaging, 2, 273-282.
[13] Geraci, M.J., Brown, N. and Murray, D. (2012) Thallium-201 for Cardiac Stress Tests: Residual Radioactivity Worries Patients and Security. Journal of Emergency Medicine, 43, e439-e442.
[14] Kol, R., Pelled, O., Canfi, A., Gilad, Y., German, U., Laichter, Y., et al. (2003) The Interference of Medical Radionuclides with Occupational in Vivo Gamma Spectrometry. Health Physics, 84, 756-763.
[15] Parker, J.A. (2001) Cardiac Nuclear Medicine in Monitoring Patients with Coronary Heart Disease. Seminars in Nuclear Medicine, 31, 223-237.
[16] Gill, J.B., Ruddy, T.D., Newell, J.B., Finkelstein, D.M., Strauss, H.W. and Boucher, C.A. (1987) Prognostic Importance of Thallium Uptake by the Lungs during Exercise in Coronary Artery Disease. New England Journal of Medicine, 317, 1485-1489.
[17] Kaul, S., Finkelstein, D.M., Homma, S., Leavitt, M., Okada, R.D. and Boucher, C.A. (1988) Superiority of Quantitative Exercise Thallium-201 Variables in Determining Long-Term Prognosis in Ambulatory Patients with Chest Pain: A Comparison with Cardiac Catheterization. Journal of the American College of Cardiology, 12, 25-34.
[18] Al Jaroudi, W. and Iskandrian, A.E. (2009) Regadenoson: A New Myocardial Stress Agent. Journal of the American College of Cardiology, 54, 1123-1130.
[19] Navare, S.M., Katten, D., Johnson, L.L., Mather, J.F., Fowler, M.S., Ahlberg, A.W., et al. (2006) Risk Stratification with Electrocardiographic-Gated Dobutamine Stress Technetium-99m Sestamibi Single-Photon Emission Tomographic Imaging: Value of Heart Rate Response and Assessment of Left Ventricular Function. Journal of the American College of Cardiology, 47, 781-788.
[20] Gibbons, R.J., Balady, G.J., Timothy Bricker, J., Chaitman, B.R., Fletcher, G.F., Froelicher, V.F., et al. (2002) ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Journal of the American College of Cardiology, 40, 1531-1540.
[21] Myers, J., Prakash, M., Froelicher, V., Do, D., Partington, S. and Atwood, J.E. (2002) Exercise Capacity and Mortality among Men Referred for Exercise Testing. New England Journal of Medicine, 346, 793-801.
[22] Roger, V.L., Jacobsen, S.J., Pellikka, P.A., Miller, T.D., Bailey, K.R. and Gersh, B.J. (1998) Prognostic Value of Treadmill Exercise Testing: A Population-Based Study in Olmsted County, Minnesota. Circulation, 98, 2836-2841.
[23] Bernheim, A.M., Kittipovanonth, M., Scott, C.G., McCully, R.B., Tsang, T.S. and Pellikka, P.A. (2009) Relation of Dyspnea in Patients Unable to Perform Exercise Stress Testing to Outcome and Myocardial Ischemia. American Journal of Cardiology, 104, 265-269.
[24] Rao, S., Lele, V. and Lele, R.D. (2005) Prognostic Value of 99mTc-Sestamibi Stress Myocardial Perfusion Single Photon Emission Computed Tomography (SPECT) in Ischemic Heart Disease. Journal of the Association of Physicians of India, 53, 1036-1042.
[25] Calnon, D.A., McGrath, P.D., Doss, A.L., Harrell Jr., F.E., Watson, D.D. and Beller, G.A. (2001) Prognostic Value of Dobutamine Stress Technetium-99m-Sestamibi Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging: Stratification of a High-Risk Population. Journal of the American College of Cardiology, 38, 1511-1517.
[26] Calnon, D.A., McGrath, P.D., Doss, A.L., Watson, D.D. and Beller, G.A. (1998) Prognostic Value of a Normal Dobutamine Stress Tc-99m Sistamibi SPECT Study. Journal of the American College of Cardiology, 31, 167.
[27] Zahid, M., Kapila, A., Eagan, C.E., Yusko, D.A., Miller, E.D. and Missenda, C.D. (2013) Prevalence and Significance of Electrocardiographic Changes and Side Effect Profile of Regadenoson Compared with Adenosine during Myocardial Perfusion Imaging. Journal of Cardiovascular Disease Research, 4, 7-10.
[28] FDA (2013) Lexiscan [Regadenoson] and Adenoscan [Adenosine]: Drug Safety Communication—Rare but Serious Risk of Heart Attack and Death. Drug Safety Communication, White Oak.
[29] Mann, A. and White, M.P. (1998) Role of the Technologist in Nuclear Cardiology. Journal of Nuclear Cardiology, 5, 438-441.
[30] Zecchin, R.P., Chai, Y.Y., Roach, K.A., Speerin, R., Lindsay, G., Squire, J. and Denniss, A.R. (1999) Is Nurse-Supervised Exercise Stress Testing Safe Practice? Heart & Lung: The Journal of Acute and Critical Care, 28, 175-185.
[31] Helfant, R.H., Klein, L.W. and Agarwal, J.B. (1987) Role of Cardiac Testing in an Era of Proliferating Technology and Cost Containment. Journal of the American College of Cardiology, 9, 1194-1198.

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