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1.5T Cardiac ExamCards according to the SCMR guidelines

ExamCard
de Kok, Wendy Philips Healthcare Philips Global

The Society for Cardiovascular Magnetic Resonance (SCMR) publishes guidelines for cardiac MR, to aid standardization of CMR acquisitions. As CMR evolves, it is anticipated that these will be updated and new modules may be added.

 

This contribution provides ExamCards that are set-up according to the revised SCMR-guidelines as published in JCMR in July 2008. 

 

All ExamCards can be used on the following system types:

  • Intera Power, SW release 12.1 and higher
  • Intera Master, SW release 12.1 and higher
  • Achieva Pulsar, SW release 2.1 and higher
  • Achieva Nova, SW release 2.1 and higher
  • Achieva Nova Dual, SW release 2.1 and higher

 

Required commercial packages:

  • Cardiac Specialist (for all sequences)
  • Coronary Specialist (for some sequences)

 

Please send questions, remark or suggestions for improvement to: wendy.de.kok@philips.com

 

Overview of available ExamCards:

Translating SCMR guidelines into ExamCards

The guidelines provide various modules for cardiac scanning. Each module is translated into an ExamCard. The first section of the guidelines describes the following general techniques, for which ExamCards are provided:

  • Left ventricular structure and function (module 1.2)
  • Right ventricular structure and function (module 1.3)
  • First pass perfusion (module 1.5)
  • Late gadolinium enhancement (module 1.6)

 

The second section of the guidelines describes disease specific protocols. Each related ExamCard provides the complementary sequences that should be scanned in addition to one or more of the general modules. Information on the required modules is available in each ExamCard.

 

Two sections of the guidelines are not translated into an ExamCard as they provide guidelines for stress and safety equipment (module 1.1) and for gadolinium dosing (module 1.4). These two sections are described in the text below:

Stress and safety equipment (module 1.1)

Stress MR studies should only be performed if the proper safety measures have been taken prior to the examination. According to the guidelines, the following equipment must be at hand:

 

  • monitoring equipment, such as blood pressure, ECG for monitoring of cardiac rhythm, and an intercom to communicate with the patient. (monitoring of heart rate and rhythm must be continuously, blood pressure every minute, symptoms continuously, wall motion abnormalities with every increment of dobutamine))
  • personnel must be prepared for rapid removal of the patient from the magnet. This procedure must be practiced regularly.
  • emergency resuscitation policy must be in place.
  • defibrillator
  • drugs for emergency treatment. Betablocker (e.g. esmolol or metoprolol), nitroglycerin, aminophylline must be immediately at hand. Moreover, a full set of emergency druygs (including drugs such as epinephrine, betablockers, atropine, bronchodilators and antiarrhythmic drugs) must be present in the emergency cart
  • For dobutamine stress testing, on-line assessment of wall motion during image reconstruction performed immediately after image acquisition is required

 

Stress agents:

  • Dobutamine, typically at a maximum dose of 40 ug/kg body weight/min

Dobutamine is a pharmacological agent that increases cardiac contractility and heart rate, and decreases systolic vascular resistance

  • Atropine, 0.25 mg fractions typical, with a miximum dose of 2 mg

Atropine causes the heart rate to increase, and is only used during dobutamine stress exams if the target heart rate is not reached

  • Adenosine at 140 ug/kg body weight/min

Adenosine is an endogenous nucleotide and is a potent vasodilator of most vascular beds

 

Contra-indications:

In case of dobutamine, the following contra-indications are listed in the guidelines:

  • Severe systemic arterial hypertension (>= 220/120 mmHg)
  • Unstable angina pectoris
  • Significant aortic valve stenosis: peak aortic valve gradient > 50 mg Hg, or aortic valve area < 1 cm2
  • Complex cardiac arrhythmias, including uncontrolled atrial fibrillation
  • Hypertrophic obstructive cardiomyopathy
  • Myocarditis, endocarditis, pericarditis
  • Uncontrolled congestive heart failure

 

In case of adenosine, the following contra-indications are listed in the guidelines:

  • Known hypersensitivity to adenosine
  • Known or suspected bronchoconstrictive or bronchospastic disease
  • 2nd or 3rd degree atrioventricular (AV) block
  • Sinus bradycardia: heart rate < 45 beats per minute
  • Systemic arterial hypotension: < 90 mmHg

 

In case of atropine, the following contra-indications are listed in the guidelines:

  • Narrow-angle glaucoma
  • Myasthenia gravis
  • Obstructive uropathy
  • Obstructive gastrointestinal disorders

 

Patient preparation:

Informed consent must be obtained for the stress test.

To fully exert its effects, patients should refrain from the following medications for at least 24 hours prior to the examination, due to potential of counteraction against stress agents:

In case of dobutamine:

  • betablockers and nitrates

 

In case of adenosine:

  • Caffeine (coffee, tea, caffeinated beverages or foods, like chocolate, caffeinated medications)
  • theophylline
  • dipydiramole

 

Note that fasting is not usually mandatory, but is sometimes advised because recognized adverse effects of stress drugs include nausea and vomiting, which is problematic when lying supine in the restrictred space of the magnet.

 

Potential adverse effects:

Dobutamine at high doses may cause chest pain, palpitations. More severe complications are uncommon, but include:

  • infarction
  • ventricular fibrillation
  • sustained ventricular tachycardia

 

Adenosine may cause flushing, chest pain, palpitations, breathlessness. More severe side effects include:

  • transient heart block
  • transient sinus tachycardia
  • bronchospasm

Gadolinium dosing (module 1.4)

This module provides recommendations for gadolinium volumes and injection rates. Doses and injection rates are listed per indication in the table below:

 

Please note that:

  • Volumes and injection rates depend on scan duration. The values in the table are recommendations for typical scan times.
  • Injection rates are different for 1 molar contrast agents. As a general rule, divide the given injection rates by a factor of 2.
  • Contrast agents with higher relaxivity (e.g. gadobenate dimeglubine) require smaller doses.
  • Injection rate for peripheral MRA with CENTRA (or other elliptic-centric readouts) may be different than those specified below. 
  • Throughout the protocols, in the ExamCards available, the term "gadolinium" refers to gadolinium chelates

 

Download ExamCard "LV Structure and function":

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Download ExamCard "Late enhancement":
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Download ExamCard "Acute myocardial infarction":
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Download ExamCard "Chronic ischemic heart disease and viability":
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Download ExamCard "Dobutamine stress":
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Download ExamCard "Peripheral MRA (QBC)":
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Download ExamCard "Cardiac and paracardiac masses, including thrombi":
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ExamCard
Achieva 1.5T, Intera 1.5T
Release 12, Release 2, Release 2 (FreeWave), Release 2.5, Release 2.6
Explorer / Nova Dual, Gradient, Master / Nova, Nova, Nova Dual, Power / Pulsar, Pulsar
cardiac, Cardiac, Cardiac Morphology, Coronary arteries, Function Cine, Function Non-Cine, SCMR guidelines
 

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