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59 Cards in this Set

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What portion of an ECG wave represents the depolarization of the ventricles?
QRS complex
P-wave
ST segment
T-Wave
QRS complex = depolarization of the ventricles
The P wave = depolarization of the atria
The ST segment = a pause between depolarization and re-polarization of the ventricles.
The T wave = repolarization of the ventricles
A patient is only able to tolerate 3 images during a 201 TI chloride myocardial perfusion study. From those views listed...which would be the best choice to obtain?
anterior, LAO 45 degrees, and LAO 70 degrees
Within what time frame must imaging be initiated following injection of 201 TI chloride in an exercise perfusion study?
within 5 min
within 10-15 min
within 20-30min
within 4 hours
within 10-15 min
Following injection the patient continues to exercise for 30 seconds to 1 minute to allow for localization of the radiopharm. in the myocardium and imaging begins as soon as possible. Most = 10 - 15 minutes as the max. time allowed before imaging is begun. Although 5 min. would be better.... it is not usually possible to remove the patient from the excerise situation and into the imaging room.
From the following....which is the best view for calculating right ejection fraction
RAO 60
RAO 30
ANTERIOR
LAO 10
RAO 30
First pass studies are used to calculate the ejection fraction of the right ventricle and are generally performed using the 30 degree LAO position
Of the choices offered, which is the best view for calculating left ejection fraction?
ANTERIOR
LAO 5
LAO 45
LEFT LATERAL
LAO 45
Of the choices offered; the 45 degree LAO is the best for imaging when calculation of the left ventricular ejection fraction
Question 6
page 68
Ejection Fraction is the portion of blood in the ventricle that is pumped out with a single heartbeat. Ejection fraction is calculated as a % of the counts at end diastole
Because the counts given in this question is net counts..... we do not need to subtract bkg.
The left ventricular ejection fraction determined in question 6 is within normal range
true
false
false
Ejection Fraction of the left ventricular is usually considered normal if above 50% or 55%.....
Normal EF for the right ventricle is plus 40%
Question 8 & 9 refer to graph.
Page 69
Question 10 refer to page 70
page 70
Question 11 needs to be worked out
page 70
A right anterior oblique is useful for: (RAO)
-facilitating calculation of LVEF and RVEF on first pass
- seperation of ventricles from stomach on first pass
- visualizing the lateral wall of the left ventricle
- increasing patient comfort and potentially improving image quality
facilitating calculation of LVEF and RVEF on first pass

First pass studies are often performed using an RAO of 10-30 degrees in order to allow calculation of ejection fraction for both right and left ventricles. This position also separates ventricular from atrial activity
What will reverse the effects of dipyridamole?
dobutamine
cholecystokinin
aminophylline
adenosine
thallium
aminophylline
Dipyridamole, adenosine, and dobuamine can be used to produce pharmacological stress....The side effects of dipyridamole can be reversed by using aminophylline, which should be on hand during and for one hour following dipyridamole adm. Side effects of dipyridamole include agina, dizziness, and nausea etc
The vertical long axis view of the heart is most comparable to a
coronal image
sagittal image
transverse image
sagittal image
Vertical long axis slices show sections of the left ventricle from the sptum to the free wall and are most similar to sagittal images
Which of the following will most negatively affect radionuclide ventriculography?
sinus tachcardia
sinus bradycardia
long QT interval
occasional PVC
sinus arrhythmia
sinus arrhythmia
The R wave signals that start of data collection, but each R-R interval is divided into segments, so if the R-R interval varies....as it does in arrhythmia, the data will be degraded. If the data is filtered out.....the exam time will be increased
An alternative to exercise studies, pharmacologic stress can be achieved through the use of any of the following EXCEPT
dipyridamole
aminophylline
dobutamine
adensinethe
aminophylline = MAY BE USED TO REVERSE the side effects of dipyridamole which is used to create pharmcologic stress, as are adenosine and dobutamine

The multigated analysis of the left ventricular, end systole is best described as
none of the above
page 71
end systole is represented by he frame with the lowest number of counts in the ROI around the left ventricle
All of the folllowing will negatively affect a myocardial study with 201 Tl chloride except:
-wrong collimator
- arrhythmia
- incorrect COR
- increased patient to detector distance
- none of the above
arrhythmia
The quality of a non-gated study would not be affected by arrhythmia, but using the other choices will
Question 19
page 72
Which of the following does not describe correct preparation for an exercise myocardial study?
NPO at least 4 hours prior to adm.
catheter placement for injection of isotope
halt all medication 24 hours prior to study
none of above
halt all medications 24 hrs before study
Patient's should be NPO 4 hours before the exam......Caffinated beverages are also restricted after midnight before the day of the exam..... Medications may or may not be taken before the exam according to the needs of the patient. Intravenous access is always in place before exercise begins to facilitate the adm. of the radiopharmaceutical
During an exercise gated study, the ECG pattern suddenly becomes dramatically different, although the patient is responsive, has an unchnaged pulse rate, continues to exercise, and has no pain. The tech should first:
- start CPR
- call a code
- check for disconnected lead
- call the referring physician
- do nothing
check the lead
Which of the following radiopharmaceuicals is not used to study the heart?
99m Tc sestamibi = myocardial perfusion imaging
99m Tc HSA = used for cardiac blood pool scintigraphy
99 m Tc PYP = MUGA tagging
32P chromic phosphate = P32 is a beta emitter and has therapeutic applications
both b & d
32P chromic phosphate
Which of the following is not a critical factor in obtaining a gated first pass study?
- tracer bolus of small volume
- regular heartbeat
- use of multi-crystal gamma camera
- positioning heart in the center of FOV
- injection of at leat 10 mCi of tracer
use of a multi-crystal gamma camera
THE radioactive dose should be adm. in a small volume as possible....in the hope that the bolus will be intact upon entering the heart....because the first pass study represents very few heartbeats, it is important that those beats not be rejected. As with all dynamic studies, careful positing is critical.
Hot markers can be used to ascertain that the sternal notch and the ziphoid process are within the FOV.... and the detector head should be in a RAO poistion.
A multi-crystal camera is idealec. of the high count rate...but is not necessary... a high- sensitivity collimator is also preferred
The best collimator for use during a first pass study is:
LEAP
high sensitivity
high resolution
medium energy
high sensitivity
Question 25
need to look into more in dept....page 73
Question 26
needs to be looked into more in dept....page 75
In general, the 45 LAO should allow visualization of the septum and the inferoapical and posterolateral sections of the left ventricular wall.
The anterior would then show the inferior, apical and the anterolateral wall sections and the 70 degree LAO would allow evaluation of the anterior, apical, inferior and posterolateral all sections.
If there is not the septum is not well resolved on the 45 LAO.....due to the patient's anatomy....another angle could be chosen...and the remaining two angles calculated by the subtracting 45 degrees for the "anterior" and by adding 25 degrees for the steep lateral oblique
Cardiac contraction is initiated in the
SA node
AV node
bundle of His
P wave
SA node
The action potential that causes contraction arises in the sinoatrial (SA) node which is located in the right atria. It then arises to the AV node and through the bundle of HIS. This bundle of HIS branches into the right and left bundle branched which end in the Purkinjie fibers; these intervate the individual contractile myocardial cells. The P-wave is that part of the ECG that represents the depolarization of the atria.
Treadmill exercise tests increase heart rate by
increasing the slope of the treadmill
increasing the speed
simulating infarct
all of the above
a and b only
a and b only
A commonly used exercise protocol is the Bruce protcol which gradually increases both the speed and the slope/grade of the treadmill. A false-negative exercise myocardial perfusion study may be the result of insufficient exercise.
A high resolution collimator would be most appropriate for
-myocardial perfusion study with 201Tl chloride
-myocardial perfusion with 99m Tc sestamibi
-first pass study with 99mTc DTPA
-myocardial imaging with 99m Tc pyrophosphate
myocardial perfusion with 99m Tc sestamibi
The high photon flux involved with Tc-99 sestamibi necessitates the use of a high resolution collimator. It is sufficient to use a low energy all purpose collimator (LEAP) for the TI201 exam as well as the infarct study with pyrophosphate.......High Sensitivity collimation is preferable to a first pass study
Question 30
page 75... need to look into more
Tc-99 PYP or Pyrophosphate and other bone agents will bind in sites of myocardial injury because calcium will travel to damaged cells. But this does not take place until at least 12 hours, and more often between 24-72 hours after an infarct has occured. The scan should not take place before 24 hours after the suspected event.
Infarct-avid myocardial imaging with 99m Tc PYP is usually interpreted by comparing cardiac activity with:
rib
sternum
kidneys
all of the above
a and b only
a and b only
uptake in the myocardium is sually compared to the uptake in the ribs and sternum when interpreting infarct studies
Question 32
needs to be worked out page 75
Gated equilibrium cardiac blood pool images can be used to reliably determine:
hibernating myocardium
LVEF
inter ventricular shunt
ischemia
all of the above
LVEF
Gated blood pool imaging of the heart can be analyzed to determine the left ventricular ejection fraction. Hibernating myocardium and ischemia can be assessed using myocardial perfusion imaging, and intracardiac shunt may be determined by a gated first pass study
Akinesis refers to
a lack of wall motion = akinesis or no wall motion
diminished wall motion = hypokinesis
paradoxcial wall motion = dyskinesis
septal wall motion
lack of wall motion
The R-R interval represents::
only re-polarization
arrhythmia filtering
the length of cardiac cycles
length of time data is held in a buffer before being accepted or rejected
the R-R interval represents the length of the cardiac cycle. In patients with rhythm disturbances, the R-R interval may vary. Since gated imaging involves division of the interval into equal parts, if the interval is not of constant length, the part of the cycle that is being imaged will vary from cycle to cycle, and the resulting images will be compromised. For this reason, arrhythmia filtering is used; data from cardiac cycles that vary too much in length are rejected
When labeling RBCs with Tc-99 for radionuclide ventriculography, the highest labeling efficiency will be obtained by
the invivo method = results in free Tc localizing in the kidneys, bladder, stomach, thyroid, and salivary glands

the invitro method = the highest labeling efficiency results from invitro.

the modified invivo/invitro method
all results in the same labeling efficiency
invitro method
Which of the following cases must imaging be initiated as soon as possible after radiopharmaceutical injection?
radionuclide ventriculography with 99mTc labeled RBCs
radionuclide ventriculography with 99 Tc HSA
myocardial perfusion imaging with 99 Tc sestamibi
resting myocardial perfusion with 201 Tl chloride
radionuclide ventriculography with 99 Tc HSA
When labeled HSA is used, the radiopharmaceutical will eventually be taken up by the liver....for this reason...cardiac imaging should begin immediately after injection
A patient has an enlarged left atrium. When drawing an ROI for calculation of LVEF following radionuclide ventriculography, the tech. includes some activity from the left atrium. The resulting ejection fraction will be
unchanged
falsely elevated
falsely lowered
cannot be determined
falsely lowered
If the ROI drawn around the left ventricle is incorrectly drawn to include some of the left atrium....the resulting ejection fraction will be falsely low
Gated blood pool ventriculography is often used to
-diagnose arrhythmia
-obtain a baseline measurement of cardiac function in potential radiation therapy patients
-detect hematologic spread of metastases
- determine effect of chemotheraphy on cardiac function
determine effect of chemotheraphy on cardiac function
- gated blood pool ventriculography is useful for determining the effect of chemotheraphy on cardiac function. In general, if the LVEF is less than 45% the cardiotoxic therapy may be stopped..... or if a change in LVEF is more than 15% the therapy may be considered to be too dangerous to cardiac function to continue
Set up for a SPECT imaging of myocardial perfusion with 99m Tc sestamibi includes all of the following except:
-ensuring that the detector head will snag IV lines or oxygen tubing
- setting a 10 degree caudal tilt to differentiate left atrium from left ventricle
- moving patients arms over heads
- ensuring the COR correction for high sensitivity collimator is selected
setting a 10 degree caudal tilt to differentiate left atrium from left ventricle
- In the case of myocardial perfusion imaging...the separation of the left atrium from the left ventricle is not as important as it is in ventriculography, so the caudal tilt is not important....all others are important
A patient who cannot excerise and who has asthma cannot undergo a stress myocarial perfusion study through the use of
the Bruce protocol
dipyridamole
dobutamine
adensosine
dobutamine
- dipyridamole, dobutamine, adensosine may all be used to produce pharmacologic stress or as an adjunct to exercise. All of these are associated with side effects but both dipyridamole and adenosine may cause or worsen bronchospasm and so should not be used in patients with asthma or COPD
A patient will be asked to fast or to eat lightly between stress and redistribution studies with 201 Tl chloride because
-persistalsis will degrade images
-stomach activity may obscure myocardium
- gall bladder contraction will be stimualted
- the patient will experience nausea following the stress test
stomach activity may obscure myocardium
Which of the following can be used to assess myocardial perfusion, right ventricle ejection fraction and left ventricle ejection fraction with a single injection?
201 Tl Chloride
99m Tc PYP
99m Tc laveled RBCs
99m Tc- sestamibi
Tc- 99m sestamibi
Tc99 has superior imaging characteristics compared to 201TI and can be used to image myocardial perfusion at 1-3 hours after injection. The disadvantages to 99mTc sestamibi is that 2 doses need to be injected for imaging of perfusion under stress and at rest. Another alternative is to perform a resting study with 201TI followed by a stress study using 99mTc sestamibi. In addition, a first pass study and gated myocardial images can be obtained with 99mTc sestamibi, although radionuclide ventriculography is typically done with labeled erythrocytes or albumin. 99m-Tc PYP and labeled erythrocytes are not used for assessment of mycardial perfusion
Choose the correct order in which the structures appear during a first pass study
right ventricle, pulmonary artery, lungs, pulmonary veins, left atrium
The tracer first enters the right heart......leaves the right heart via the pulmonary artery....and enters the lungs...The oxygenated blood enters the pulmonary vein and is carried to the left side of the heart
Which of the following is the most likely cause of false anterior or lateral wall defects on myocardial perfusion imaging with 201 Tl chloride?
center of rotation error
respiratory motion
too few projections
attenuation by breasts tissue or implant
Attenuation from breasts tissue and breast implants may create the appearance of defects in the anterior and lateral walls of the heart.....If the patient is not positioned in the same way for stress and redistribution studies.....this may appear to be true...reversible defect.....so positioning must remain constant
During a one day myocardial perfusion study with 99m Tc sestamibi including both stress and rest:
- the rest images must be obtained before stress images
- the second dose of sestamibi should be higher than the first
- the highest dose of sestamibi is always injected for the stress portion
- the sestamibi doses should be identical for best comparasion of stress and rest
the second dose of sestamibi should be higher than the first

the stress study is performed first, followed by a second injection of higher dose for the resting study
Why is it necessary to inject 2 doses of 99m Tc sestamibi for a myocardial perfusion study including both stress and rest conditions?
- because the physical half life of 99m Tc is too short to obtain both images sets from one injection
- because there is no redistribution of 99m Tc sesamibi within the myocardium
- because the effective half life is too short
- because sestamibi is not retained by the myocardium for a sufficent time
because there is no redistribution of 99m-Tc sestamibi within the myocardium
the second injection of 99-Tc sestamibi is required, because unlike 201TI, there is no redistribution of sestamibi in the myocardium

Soft tissues attenuation is least problematic in
myocardial imaging with 99m-Tc sestamibi than with 201 Tl chloride
because of the higher photon energy of 99mTc relative to 201TI, attenuation is less likely in Tc
The bulls eye display created after myocardial perfusion imaging represents?
-only short axis images
- an entire set of stress or rest SPECT images
- all part of the myocardial wall except the apex
- none of the above
- b and c
an entire set of stress or rest SPECT images

- a bull's eye display or polar map is creating from the entire set (either stress or rest) of perfusion images......so it includes all walls of the myocardium. It offers a convenient way to compare stress and rest data sets.
Differences between myocardial perfusion imaging with 201 Tl chloride and 99 Tc sestamibi include:
higher photon flux with 99m- Tc
The LEAP collimator is used with 201TI
There is less soft tissue attenuation with 99Tc.....
The delay between excerise and rest is the same for both isotopes...

There is higher photon flux from the 99Tc dose
When performing a radionuclide venogram to visualize deep venous thrombosis, what should be injected and where?
99m-Tc MAA in bilateral pedal veins
The radionuclide venogram for deep venous thrombosis involves imaging the deep venous flow from the feet through the lower extremities. One to 1.5 mCi of Tc MAA is injected into the pedal vein atop each foot. To prevent clumping......it is important not to withdraw blood into the synringe before injection.....
Following injection of Tc-99m sestamibi, during a resting myocardial perfusion study, imaging is delayed for one hour because?
- respiratory motion will decrease
- liver and lung activity is too high to allow high quality images of the myocardium
- until 1 hour after injection, sestamibi has not had sufficient time to be taken up by the myocardium
- the patient should be monitored for adverse reactions during the first hour
liver and lung activity is too high to allow high quality images of the myocardium

- initial uptake of 99-Tc sestamibi into the liver and lungs can obscure the myocardium. For this reason...... imaging does not begin immediately. A fatty meal, or milk may stimulate the GB contraction and some activity may be distributed ino the bowel
When performing a dual isotope myocardial perfusion rest/stress study....which isotope should be injected first?
201 TI
99mTc
it does not matter which is injected first, as long as Tc is used for the stress study
either can be injected first without any problems
201 Tl
The lower energy isotope (201TI) should be imaged first, to prevent interference from the higher energy photons.....Because attenuation is a bigger problem with 201TI.......the excerise study is best performed with 99mTc.
WHICH of the following technical considerations are applicable for radionuclide venography?
-tourniquests applied about the ankles and just below the knee
- radioactive markers taped above each patella
- knees elevated with a pillow
- all of he above
-tourniquests applied about the ankles and just below the knee
False negative stress myocardial perfusion studies are usually caused by
-failure of the myocardial to extract 201 Tl chloride from the bloodstream
- electrocardiogram leads
- failure of the patient to reach maximal stress
- thallium contained in too large volume
failure of the patient to reach maximal stress

If the patient fails to reach maximal stress.....false negatives may result...the maximal stress is usually defined as 85% of a predicted max. heart rate.... usually 220 - age in years....but may also be to the point that chest pain or significant ECG changes occur....or when the systolic blood pressure multiplied by the heart rate is greater than 25,000
Which of the following should be prepared ahead of dipyridamole stress myocardial perfusion study?
- dose of dipyridamole
- dose of radiopharmaceutical
- dose of aminophylline
- all of the above
a and b only
all of the above
- the dipyridamole (0.56mg/kg body weight) is injected first..normally over 4 minutes.... the radiopharm. is injected after 7 or 8 minutes and the aminophylline should be prepared in advance for injection in case of serious side effects ( side effects may include chest pain, dizziness, headaches and nausea)
During a MUGA scan...... data collection is stopped when:
when either a preset number of counts or a preset number of cardiac cycles has been reached
A tech. injects a patient with 1 mg of unlabeled stannous phosphate. After 20 minutes, 20 mCi of 99m-Tc is administered. This is
an invivo labeling procedure
Invivo method = labeling takes place inside the body.......
Invitro means = labeling takes place outside the body
The modified invivo = injecting the reducing agent into the patient....then withdrawing and labeling the blood invitro before reinjecting the blood
A disadvantage of using 99m Tc HAS for radionuclide ventriculography includes
- high radiation dose
- lung uptake
- liver uptake
- relatively low photon flux
- difficult labeling procedure
liver uptake
Although HSA may be used.......it will be taken up by the liver so imaging must begin promptly after injection
Which of the following may have an effect on the time it takes to acquire a cardiac gated blood pool study?
- amount of radiopharmaceutical injected
- heart rate
- use of arrhythmia filtering
- all of the above
- a and b only
all of the above
Cardiac gated blood pool study = MUGA = Depending on what parameters are set for data collection ( total counts or cardiac cycles) all of the choice may affect imaging time and ( the data collection time may be fixed by setting a count number to be reached, or by the setting the number of cardiac cycles