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  • Heart failure (HF) is a highly prevalent condition with [a] high mortality rate.

  • Accurate quantitation of left ventricular function is possible with gated single-photon emission computed tomography (SPECT), positron emission tomography (PET), and radionuclide ventriculography.

  • Nuclear cardiology is helpful in distinguishing ischemic from nonischemic cardiomyopathy in many patients, particularly in those without symptoms or risk factors for coronary artery disease.

  • Nuclear cardiology techniques can accurately quantify myocardial ischemia and viability.

  • Risk stratification of HF patients may be enhanced with neurohumoral imaging, assessment of myocardial blood flow, and ventricular remodeling.

  • PET has particular utility in patients with suspected cardiac sarcoidosis and for the surveillance of posttransplant patients for allograft vasculopathy.

Despite many advances in recognition and treatment, chronic heart failure (HF) is an increasingly prevalent condition with a high mortality rate.1,2 The successful treatment of HF patients requires establishing an accurate diagnosis; identifying potentially reversible etiologies; determining the optimal therapy, which may be medical, percutaneous, or surgical; and assessing risk of patients at high risk for worsening HF or sudden cardiac death. Several of these aspects of HF care can be gainfully evaluated by radionuclide imaging. This chapter will provide a broad overview of established applications of radionuclide imaging in HF. Additional chapters will provide a more detailed overview of specific techniques and their applications.

The clinician has several goals when evaluating an HF patient. Once a clinical diagnosis of the syndrome of HF is made, the initial step is usually the assessment of left ventricular function, often with the accurate determination of left ventricular ejection fraction (LVEF). Approximately one-half of patients will have HF with preserved ejection fraction (HFpEF, EF ≥ %50%), while the remainder will have either HF with reduced ejection fraction (HFrEF, EF < 40%) or HF with mid-range EF (41−50%), a recently proposed category.3 Radionuclide imaging methods including single-photon emission computed tomography (SPECT), radionuclide ventriculography (RVG), and positron emission tomography (PET) can all provide highly accurate and repeatable quantitative measurements of LVEF. Despite a similar prevalence to HFrEF, absent specific infiltrative etiologies, such as cardiac amyloidosis or sarcoidosis, no therapeutics have been shown to improve survival in patients with HFpEF. Treatment of HFpEF focuses upon the identification of treatable causes including coronary artery disease (CAD) and management of comorbidities including obesity, hypertension, and atrial fibrillation. Patients with HFpEF require an evaluation for CAD, and absent presentation with acute coronary syndrome or chest pain, this is often done with nuclear imaging.4 A specific case in point regarding radionuclide imaging in HFpEF patients is cardiac amyloidosis. The emergence of Tc-99 pyrophosphate imaging as a noninvasive diagnostic standard for ATTR cardiomyopathy (Chapter 25) has been transformative for the field by unmasking a hitherto unrecognized prevalence of the condition in patients with HFpEF.5 Together with the introduction of first specific therapies for cardiac amyloidosis, Tc-99 pyrophosphate has invigorated clinical and academic interest in the field. Similarly, PET imaging ...

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