Myocardial Perfusion Imaging during the Coronavirus Pandemic (COVID-19)

The global outbreak of Coronavirus (COVID-19) was declared a pandemic by the WHO (World Health Organization) on March 11, 2020¹. Despite intense global efforts to curb the spread (or flatten the curve) of COVID-19, there are more than 11 million cases and over 500,000 deaths worldwide¹. Currently, there is no vaccine available for COVID-19.

The WHO, Centers for Disease Control (CDC), as well as local government and health officials recommend several steps to protect yourself and others. Guidance includes washing your hands for at least 20 seconds, keeping a distance of 6 feet from others (social distancing), wearing a face mask or cloth cover in public places where keeping distant is not possible, coughing\sneezing into your arm, disinfecting frequently touched surfaces, and monitoring your health for any symptoms of COVID-19^1,2.

During the peak of the pandemic, medical specialty societies^3,4,5 and governmental agencies⁶ recommended postponing or even cancelling non-urgent nuclear cardiac studies. Since healthcare facilities may be highly susceptible environments for COVID-19, it is important to consider implementing special precautions to protect patients and healthcare staff, while maintaining the ability to provide proper care, testing and management of patients.  Certain populations, such as older adults and people who have severe underlying medical conditions such as heart disease, lung disease or diabetes seem to be at higher risk for developing serious complications from COVID-19².

The Society of Nuclear Medicine and Molecular Imaging (SNMMI), American Society of Nuclear Cardiology (ASNC) and International Atomic Energy Agency (IAEA) have released information statements on how to safely manage nuclear cardiology patients and healthcare staff during the COVID-19 pandemic^3,4. These information statements include important considerations for imaging departments who are performing nuclear cardiology imaging for urgent indications to reduce the risks to certain populations and the potential spread of COVID-19. These statements also include precautionary steps for those facilities starting to re-establish nuclear medicine imaging studies for non-urgent care indications as local regulations ease.

In nuclear cardiac laboratories performing Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI), it is recommended to perform stress only or stress first and for inpatients requiring MPI that are not eligible for stress only, consideration should be made to inject the rest dose in the patient’s room to avoid having the patient spend unnecessary time in the nuclear department³.

If nuclear laboratories have access to Positron Emission Tomography (PET), this modality is preferred for MPI because of its short duration³. A complete rest-stress Rubidium-82 PET MPI study can be completed within 30 minutes, minimizing exposure for patients and staff, and also potentially reducing number of rooms and spaces which could experience surface contamination. If using N-13 ammonia for PET MPI, consider leaving the patient on the camera bed to facilitate a single rest/stress session and avoid having the patient leave the camera room between rest and stress portions of the study. In addition, a low-dose rest\high-dose stress protocol may help make the study shorter in duration³.

For patients undergoing MPI with either SPECT-CT or PET-CT, some laboratories recommend implementing a policy of reviewing the CT images to detect patients with infiltrates that might be infectious with COVID-19 but who may not be aware⁷.

Minimizing the number of healthcare personnel that comes into contact with each patient, wearing appropriate personal protective equipment (PPE) and performing pharmacological stress with vasodilators as preferred method of stress (over exercise stress) to minimize droplet exposure are important measures that may be taken for the safety and protection of everyone involved⁴.

With recommendations constantly changing, there are several factors to consider that require careful thought when scheduling and performing nuclear cardiology studies. It is important to evaluate procedures for scheduling and performing patient procedures during this pandemic and implement the best practices to protect both patients and healthcare personnel, while continuing to provide quality imaging for proper diagnosis and patient management.

References:

1. World Health Organization website. www.who.int, accessed July 5, 2020

2. Centers for Disease Control and Prevention website. https://www.cdc.gov/coronavirus/2019-nCoV/index.html, accessed July 5, 2020.

3. Skali, H et al. Guidance and Best Practices for Reestablishment of Non-Emergent Care in Nuclear Cardiology Laboratories during the Coronavirus Disease 2019 (COVID-19) Pandemic: An Information Statement from ASNC, IAEA, and SNMMI. https://zenodo.org/record/3827461, published May 14, 2020.

4. Skali, H. et al. Guidance and best practices for nuclear cardiology laboratories during the Coronavirus disease 2019 (COVID-19) pandemic: An Information Statement from ASNC and SNMMI. Journal of Nuclear Cardiology; March 27, 2020 doi:10.1007/s12350-020-02123-2

5. Center for Disease Control and Prevention. Healthcare facilities: preparing for community transmission. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hcf.html. Accessed April 30, 2020.

6. Center for Medicare and Medicaid Services. Non-emergent, elective medical services and treatment recommendations. https://www.cms.gov/files/document/cms-non-emergentelective-medical-recommendations.pdf. Accessed April 30, 2020.

7. Loke KSH et al. Adapting to a novel disruptive threat: Nuclear Cardiology Service in the time of the Coronavirus (COVID-19) Outbreak 2020 (SARS REBOOT). J Nucl Cardiol 2020; doi:10.1007/s12350-020-02117-0.