Pitfalls and limitations of radionuclide and hybrid cardiac imaging

Radionuclide myocardial perfusion imaging (MPI) is an important technique for evaluating the presence and severity of ischemic coronary heart disease that is widespread in the United States and much of the world. This widely used test has excellent diagnostic accuracy and strong risk-stratification utility and plays an important role in guiding patient management. As with all testing modalities, the clinical utility of MPI relies on proper procedure performance as improper techniques can lead to incorrect test interpretation, and thus misdiagnosis with potential adverse effects on patient management and outcome. A variety of potential pitfalls must be understood and recognized. These include minimizing referral of "rarely appropriate" patients for testing, selecting the best imaging procedure for each patient, properly preparing a patient for the test to be performed, skillful performance of stress testing and image acquisition, careful image processing, understanding the strengths and weaknesses of different image display options, recognition of common artifacts that can lead to misdiagnoses, distinguishing normal anatomy from true pathology, recognizing noncoronary cardiac disease, and not missing extracardiac pathology. It is important that physicians who perform and interpret radionuclide MPI be well versed in published guidelines and potential pitfalls to proper test performance and interpretation.