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TiP-TV® Training in PartnershipProgram Supplement and Testfor Imaging Professionals

CT: Comparative Cardiac Imaging

Publication Date: February 19, 2009

1.0 ASRT-approved Category A CE Credit

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GE Healthcare CT: Comparative Cardiac Imaging

REV 0 Program Supplement and Test

TABLE OF CONTENTS

Program Summary.......................................................................................................................................................................3Continuing Education Credit and Video File Download (**NEW**) ..........................................................................4Introduction.....................................................................................................................................................................................5Cardiac Catheterization vs. Other Modalities ...................................................................................................................6Nuclear Medicine ..........................................................................................................................................................................7Cardiac PET and CT ......................................................................................................................................................................8CT Coronary Angiography and PET Image Review .........................................................................................................9Magnetic Resonance Imaging.............................................................................................................................................. 10Sonography .................................................................................................................................................................................. 11Appendix A: Presenters ................................................................................................................................................................... 13Appendix B: Resources .................................................................................................................................................................... 14Appendix C: Post-Test ...................................................................................................................................................................... 15

© 2009 General Electric Company. All rights reserved. 2 of 17



Program Summary

This page provides an overview of the program content and learning objectives. The Table of Contents provides a detailed list of the topics covered. Please keep a copy of this Program Summary and the Table of Contents with your continuing education certificate. It is also recommended that you provide a copy of this information to your manager as a record of your educational achievement.

Program Description and Target Audience

This is a multi-focused program in which discussion pertains primarily to the study of cardiac CT. However, because there are several methods used to assess heart morphology and function, this program compares and contrasts CT to invasive catheter angiography, MRI, ultrasound, nuclear, and PET scanning. Included are pathology examples associated with coronary vascular disease, and patient workup from diagnosis and treatment through follow-up. The course objectives specifically target CT technologists.

Program Objectives

By the end of this program, the viewer should be able to:

1. Review imaging modalities that provide evaluation of cardiac morphology, function, and vasculature.

2. Compare and contrast the imaging potential of computed tomography, catheter angiography, nuclear medicine, positron emission tomography, magnetic resonance, and sonography in the assessment of cardiac disease.

3. Recognize the mechanisms and vascular effects of atherosclerotic disease.

4. Describe the value of CT angiography and calcium scoring for coronary artery disease (CAD).

5. Define the anatomy of the heart’s major arteries.

Continuing Education Credit

1.0 ASRT-approved Category A CE Credit

NOTE: While the technical content is most effective for the target audience, other technologists and medical personnel may also benefit from viewing this course. Regardless of your imaging specialty, you may apply for continuing education credit . Refer to the Continuing Education Credit page for additional information.




Continuing Education Credit and Video File Download (**NEW**)

Online Process for CE Credit (hls.gehealthcare.com)

In order to receive continuing education credit , you must log into the GE Healthcare Learning System (HLS) and complete all of the required steps. Please refer to the online TiP-TV Quick Start User Guide (click the User Guides link on the HLS Welcome page) for additional information on how to use the GE HLS as needed.

1. View the entire program video online or download the video file for later viewing (refer to the process below). This supplement is not intended to replace watching the video.

2. Go to the GE HLS web site at hls.gehealthcare.com and complete the feedback form.NOTE: The Feedback Form link is not activated until the View Video Now module has been completed. This provides valuable information regarding your thoughts on the program’s quality and effectiveness.

3. Complete the program post-test without aids or assistance of any kind; this is an individual effort . You have up to three attempts to successfully complete the test with a minimum passing score of75% (ASRT-approved programs) or 80% (SNM-approved programs).The post-test measures knowledge gained and/or provides a self-assessment on a specific topic.

4. Upon successful completion of the online CE information, you can instantly print a certificate.

5. Florida residents: The process for submitting CE credit to the FL DOH can be found online in the Related Documents tab on the bottom of the program’s Item Details page.

Video Download Process (**NEW**)

For programs with an original start date of September 1, 2008 or later, the GE HLS includes an option to download the TiP-TV program video file. You can then watch the program on your personal computer or transfer the video file to your portable video player for viewing.

NOTE: Please refer to the TiP-TV Video Download Quick Start Guide for complete details (click the User Guides link on the GE HLS Welcome page).

• With the desired program in your GE HLS Learning Plan, launch the program content to view the Online Content Structure. In the Video Download (Optional) area, click the Download Video to View Later link.

• Save the video file on your personal computer, using your existing video download software.• View the program on your personal computer or transfer it to your portable video player for later viewing.• After viewing the entire program, log into the HLS and complete the CE activities as noted above.

Continuing Education Credit Eligibility — Important Notice!

A GE Healthcare TiP-TV course may be available in several different formats, such as an online web course or CD/DVD. You may only be able to receive CE credit once for a particular course, regardless of the format in which it was viewed. If you have already received credit for a course, you are encouraged to contact your CE certification organization (ARRT, NMTCB, ARDMS, etc.) to determine if you can repeat this course for CE credit .

Thank you for choosing GE Healthcare as your continuing education partner. We hope you will join us for other TiP-TV programs in the future. For more details and program schedule information, please visit our education web site (www.gehealthcare.com/education).

Please forward any questions or comments to: [email protected]




Introduction

This is a multi-focused program that discuses the evaluation of cardiac morphology, function, and vasculature. Computed tomography, invasive catheter angiography, nuclear medicine, positron emission tomography (PET), magnetic resonance imaging (MRI), and sonography are looked at. Examples of selected pathology associated with cardiac disease are also discussed.

The focus of this program is on the entire heart; however, a considerable amount of information pertaining to coronary artery disease is added, because it still remains the leading cause of death in the United States (U.S.). Statistics reveal about 1.5 million myocardial infarctions occur each year, and of those, nearly 900,000 result in death. The monetary cost of treatment for coronary artery disease exceeds $60 billion, and the associated productivity loss is extraordinarily high.

The video portion of the program contains several interviews with medical personnel. This document contains the main points of these conversations in bulleted form. Please watch the video presentation in order to more fully understand the concepts discussed.

Medical personnel interviewed for this program are (in order of appearance):

• Dr. Kevin Berger, Director of PET/CT at Michigan State University in East Lansing, Michigan.

• Dr. Jack Ziffer, Chief of Department of Radiology at Baptist Hospital and Medical Director of Cardiac Imaging at Baptist Cardiac & Vascular Institute in Miami, Florida.

• Dr. Pamela Douglas, Ursula Geller Professor of Research in Cardiovascular Diseases and Director of Cardiovascular Imaging Center at Duke Clinical Research Institute in Durham, North Carolina.

• Dr. Susan Jensen, Interventional Cardiologist at Memorial Hospital in Colorado Springs, Colorado.

• Dr. Marcelo DiCarli, Chief of Nuclear Medicine/PET at Brigham and Women's Hospital, Harvard Medical School in Boston, Massachusetts.

• Ms. Cindy Comeau, Manager of Cardiovascular MRI and Co-director of MRT Core Lab at Advanced Cardiovascular Imaging in New York, New York.

• Dr. Claudia Korcarz, Manager of the Atherosclerosis Imaging Research Program at the University of Wisconsin Hospital in Madison, Wisconsin




Cardiac Catheterization vs. Other Modalities

Over one million diagnostic cardiac catheterizations are performed to define coronary artery disease and determine appropriate treatment options. The procedure is associated with high cost, in the range of $3,000 to $6,000, and carries a notable radiation exposure to all personnel involved. Cardiac catheterization also carries a small but serious risk of developing complications.

There are other drawbacks associated with cardiac catheterization, in particular, the inability of the procedure to define the anatomy of the arterial wall. It also cannot assess blood perfusion to myocardial tissue. These shortcomings often necessitate additional tests to evaluate the functional and morphological impact of coronary artery disease.

NOTE: Dr. Berger and Dr. Ziffer comment in the program video.

Currently, two of the most common uses of CT in cardiology are:

• Coronary artery calcium scoring – provides a noninvasive predictive likelihood of future coronary events.

• CT coronary angiography – requires some of the most advanced CT equipment, as in the 64-slice multidetector CT units.

Additional information:

The indications for using CT in cardiology are evolving rapidly. In the next several years there will be dramatic changes in recognized and evidenced-based approaches to evaluating patients.

• In patients with chest pain that is thought to be caused by coronary artery disease, a CT coronary angiogram is very effective at excluding coronary artery disease, especially if normal.

• There can be challenges to CT angiography in patients in whom the heart rate cannot be slowed and in patients with dense coronary calcium. There can also be problems in patients with intermediate stenosis. Nuclear tests would then be relied upon to assess hemodynamic significance.

• CT has another very powerful application: evaluating patients who are asymptomatic.

Of great benefit in CT is the visualization of vessel wall characteristics. Please see the program video for an example of intramural atheroma as demonstrated with CT. The column of contrast can be seen within the artery, but in addition, there is a region that clearly represents an atheromatous plaque within the vessel wall. Wall characteristics such as this are not visible in cardiac catheterization procedures; the lumen is visible, but no wall information is provided.

There are risk categories and management strategies for men and women. Would it be fair to say the risks are the same for both genders?

NOTE: In the program video, Dr. Douglas and Dr. Jensen comment.

Notes:




Nuclear Medicine

Nuclear imaging provides information about cardiac function, myocardial perfusion, and viability. Areas of reduced myocardial perfusion can be visualized with single positron emission computed tomography, or SPECT, imaging.

NOTE: In the program video, Dr. Dicarli and Dr. Ziffer provide commentary about SPECT imaging. PET imaging also enters the conversation.

Are there inherent disadvantages associated with SPECT imaging? And if that is the case, how can the modality be improved?

• About 25 years ago, the primary mode of diagnosing CAD was invasive catheter angiography. Back in those days, functional imaging, primarily myocardial perfusion imaging with thallium, and later on with technetium tracers, eventually became the gold standard for the detection of disease. This constituted an evolution from an invasive mode to a noninvasive mode of detection.

• In addition, it was clearly shown that functional imaging was more effective in identifying patients with CAD, and also those that would benefit from revascularization procedures.

• SPECT answers important questions; for example, What is the patient's exercise capacity? Is chest pain reproduced during exercise?

• SPECT imaging has inherent limitations related to its relatively poor spatial resolution, and the inability to do accurate attenuation correction, which is the attenuation of the photons that are coming out of the heart creating defects on the images and can be confused with real disease.

• SPECT also has relatively poor temporal resolution, so there is an inability to really quantify a given process, for example, coronary blood flow.

• PET is more accurate, in general, because it has better spatial resolution; it has better temporal resolution and it also has better contrast resolution. Pet images are much more crisp, easier to diagnose, and overall are more accurate than those obtained with SPECT imaging.

• Rarely, patients can have balanced ischemia, multivessel disease, where there's a uniform decrease in blood flow with stress. Since heterogeneity in blood flow is looked for, everything's uniformly down, so pathology may not be seen.

• One of the interesting developments is adding CT to SPECT imaging, providing an attenuation correction- based imaging method.

PET is a very effective tool in determining the areas of the heart that might be affected by an ischemic event.

NOTE: The effectiveness of PET compared to SPECT has already been discussed briefly, and it is further discussed by Dr. DiCarli and Dr. Ziffer in the program video. You also hear reference to MRI, which serves to demonstrate how these modalities complement each other.

• Most of the work revolves around the detection of coronary artery disease with PET myocardial perfusion imaging.

• In patients with known coronary disease and advanced cardiac dysfunction, PET is very good at pinpointing areas of the heart muscle that are not contracting and are capable of responding to coronary revascularization.

• PET is now rapidly moving into CAD detection.




• PET has an advantage over SPECT in that there are virtually no false positives and no false negatives. The image quality is superb, principally because of very high count rates as well as very robust attenuation correction. It is more accurate than SPECT.

• Another important application of PET is the assessment of myocardial viability in patients who have a wall motion abnormality, or an abnormally functioning left ventricle. The question becomes, Would revascularization help them or not? That's important, because to put somebody through the surgical risk when there would be no anticipated benefit , would be useless and dangerous to the patient.

As mentioned earlier, SPECT and CT can be combined to change the entire paradigm. As you know by now, PET and CT have also been combined in order to provide an entire new set of options.

Cardiac PET and CT

PET, as in nuclear medicine, uses isotopes to separate what appears to be viable myocardial tissue from necrotic tissue. Most nuclear techniques are limited to provision of functional and perfusion information, but do little in the way of identifying atheromatous plaques in coronary arteries.

NOTE: In the program video, Dr. DiCarli and Dr. Ziffer talk about how the combination of PET and CT might contribute to getting around that issue.

• Most imaging techniques have suffered from a relatively low sensitivity, particularly in the most challenging patients, such as those that are overweight which, of course, is an area of growing concern because the American population is growing in size.

• A PET scanner, combined in hybrid fashion with a multislice CT scanner, allows you to get very detailed information regarding cardiac perfusion, but in the same procedure, coronary angiography with fast CT imaging can be done noninvasively in order to view coronary artery disease.

• The hybrid equipment provides a great deal of power, because you can now, noninvasively and in a very short period of time, obtain detailed information regarding the extent of anatomic coronary artery disease, as well as the functional significance of that disease, which leads to more effective management decisions.

• The CT part of the hybrid PET/CT system also provides an assessment of coronary calcium, which is a indicator of the absence or presence of atherosclerosis, and is really a test to see what the patient's long-term prognosis is, and how aggressively they need to be managed for coronary artery disease.

NOTE: In the program video, Dr. DiCarli explains how PET coupled with CT can be very advantageous for asymptomatic patients that may, nonetheless, have coronary artery disease.

• CT offers delineation of the atherosclerotic burden in the coronary arteries. These plaques may not necessarily be producing a limitation to coronary blood flow and therefore may not be symptomatic.

• If you perform a PET procedure alone, you may conclude the patient does not have coronary disease, when in fact, when CT is done, you see and measure calcified and non-calcified coronary plaques.

• So you can better determine that the patient does have evidence of atherosclerosis even though those plaques are not functionally significant; therefore, the patient may be still asymptomatic. The combination of information will lead the referring physician to consider this patient for more aggressive medical management of the factors that led to coronary artery plaques.




CT Coronary Angiography and PET Image Review

NOTE: In the program video, Dr. DiCarli presents an anatomic review of coronary CT, as well as cardiac PET images.

CT anatomic review:

• Aorta

• Coronary tree

• Left main coronary artery

• Left anterior descending artery

• Diagonal branches

• Septal branches

• Circumflex artery

• Obtuse marginal branch

• Right coronary artery and branches

Cardiac PET images from a rubidium PET examination:

• Multiple axes

• Short axis view

• Vertical and horizontal long axis views

• Look for perfusion defects.

• Gated images demonstrate cardiac function.

• Measurement of ejection fraction.

• Put together CT and PET images to provide referring physician with anatomical and functional information.

NOTE: In the program video, Dr. Ziffer and Dr. Berger comment about the future of cardiac imaging.

• In the near future, you’ll see some dramatic shifts in the workup of patients. CT will be the prime modality. For example, in the emergency room the question will not only be, Does the patient have coronary disease? but also, Do they have a dissection? Do they have pulmonary emboli? Do they have pneumonia?

• CT is a very powerful tool because with one test , you can virtually exclude or diagnose any of the life threatening causes of chest pain.

• Nuclear medicine will be used more as a problem solver to determine the hemodynamic significance of lesions that are ambiguous by CT.

• There's an intriguing possibility that SPECT/CT may offer some new opportunities. If you could bring to the SPECT world the image quality that you've gotten used to with PET, and if you could get coronary calcium with it , SPECT/CT may really offer some tremendous opportunities for improving the noninvasive workup of patients.




• With the advent of PET/CT, cardiologists and patients can be offered a rapid, accurate method of achieving results. And I think that improvement in accuracy, patient throughput, and decreased radiation exposure to patients, all are migrating toward cardiac PET/CT.

• PET/CT is going to become a central tool in the arsenal of what cardiologists have to offer to their patients. It's a single machine that can do everything that they need, from myocardial perfusion imaging, to CT coronary angiography, to cardiac calcium scoring. I think that they're going to have one machine that can replace having independent separate SPECT machines or independent separate CT machines. So for some practices, I think this offers one imaging technology solution.

Magnetic Resonance Imaging

MRI offers dynamic imaging techniques that provide cardiac function, viability, and perfusion data, as well as four-dimensional (4-D) imaging with electrocardiograph (ECG) correlated acquisitions. What is more, it is effective for identification of coronary artery stenosis.

ECG correlation is also called cardiac gating, or triggering, where image acquisition is begun by a start pulse derived from an ECG signal taken from the patient while the imaging procedure is in progress. CT uses it also. These gating techniques are useful whenever data acquisition is too slow to capture a short fraction of the cardiac cycle. Image blurring, due to cardiac-induced motion, occurs for imaging times above approximately 50 milliseconds (ms) in systole, and in diastole, the critical time is in the range of 200 to 300 ms.

NOTE: In the program video, Ms. Comeau discusses MRI cardiac work. You'll see how MRI can be effective for evaluation of valvular disease. Ms Comeau was asked to define how some of the localizations take place with MRI techniques.

• MR valvular function.

• Look for jets.

• Three-chamber views.

• Mitral and aortic valve.

• Cine viewing.

• Spoiled gradient (SPGR) echo.

• Fast imaging using steady state acquisition (FIESTA).

• Use shorter repetition times (TR) and time of echo (TE).

• Mitral regurgitation.

• Short axis views.

• Long axis views.

MRI uses pulse sequences that are designed to best demonstrate the area of interest and the clinical indication.




NOTE: In the program video, Ms. Comeau explains what some of these pulse sequences are and what might be done with more difficult patients, such as those with cardiac arrhythmias.

• Bright blood sequences.

• Black blood sequences.

• Contrast sequences.

• FIESTA – best for evaluation of cardiac function.

• Very susceptible to flow artifact on older systems, especially with longer TRs.

• Temporal resolution is very important, on the order of 50 to 80 ms.

• Parallel imaging techniques help to scan even faster, in one heartbeat.

• Atrial fibrillation patients can be done.

• Six to ten second acquisitions do not need to be done.

• Contrast sequences – perfusion imaging. Indirectly assesses coronary artery disease and myocardial viability. It is important information to know for revascularization patients. MRI is good at looking at transmural infarct. If more than 50% of the wall is involved, it probably will not respond to coronary artery bypass graft (CABG) surgery.

• Another MR technique used for valvular disease is called phase-contrast imaging. MR is the gold standard for valvular disease and exact protocols are determined by the kinds of questions being asked.

• Cardiac function parameters – MR can define stroke volume or the amount of blood ejected from a ventricle in a single beat. MR can also can evaluate ejection fraction, which is an index of contractility.

Sonography

Echocardiography is an ultrasound procedure that evaluates the shape and size of ventricular walls, as well as the heart's valves. It can assess cardiac function by looking at wall motion and can evaluate blood flow with Doppler techniques. The evaluation of coronary arteries and atherosclerotic plaques themselves is still difficult using ultrasound.

A duplex scan is a noninvasive sonographic procedure. The term "duplex" refers to the fact that two modes of ultrasound are used: Doppler and B-mode. The B-mode transducer (similar to a microphone) obtains an image of the artery being studied. The Doppler probe within the transducer evaluates the velocity and direction of blood flow in the vessel.

Brachial scanning looks at arterial function a step before arterial disease actually presents. At the University of Wisconsin, research and clinically oriented testing includes brachial artery ultrasound combined with carotid ultrasound to look for atherosclerosis.

Brachial reactivity is a physiological test that is combined with an anatomic test , in this case, carotid intima-media thickness. These studies help to assess the body's total atherosclerotic burden. There is high correlation between carotid ultrasound vascular thickness and coronary artery disease.

This indirect approach can be used to evaluate subclinical disease by measuring the body's plaque burden through extrapolation from carotid intima-media thickness data, as well as brachial artery reactivity data.




NOTE: The program video contains an example of a brachial reactive hyperemia study videotaped at the University of Wisconsin Hospital and Clinics, with Dr. Korcarz.

• Brachial reactive hyperemia studies look at epithelial function.

• The objective is to stratify risk.

• The test signals the epithelium to dilate.

• Constrictive follows by release.

• Eight to ten percent dilation of the artery is normal; if it is stiffened, the response will not reach that level.

• Used with ECG gating, measured at the R wave of the cardiac cycle.

• Normal release of nitrous oxide tells the artery to relax.

• The hyperemic response is recorded.

This case study emphasizes the fact that early detection techniques, prior to development of symptoms and prior to disease manifestation, are gaining momentum.

You can see from this discussion that there are many modalities that can be used to gather cardiac and vascular data, some of which are very complimentary, some of which are unique. Some are effective for morphological information, others for functional evaluation. Some stand alone, some are fused. And on it goes.




Appendix A: Presenters

Roger Beck, M.S., R.T. (R)(CT)CT/Leadership TiP-TV Program ManagerGE Healthcare

Special Contributors

Kevin Berger, M.D.Director of PET/CTMichigan State UniversityEast Lansing, Michigan

Cindy Comeau, B.S, R.T. (N)(MR)Manager Cardiovascular MRICo-director MRT Core labAdvanced Cardiovascular ImagingNew York, New York

Marcelo DiCarli, M.D.Chief, Nuclear Medicine/PETBrigham and Women's HospitalHarvard Medical SchoolBoston, Massachusetts

Pamela Douglas, M.D., F.A.C.C.Ursula Geller Professor of Research in Cardiovascular DiseasesDirector, Cardiovascular Imaging CenterDuke Clinical Research InstituteDurham, North Carolina

Susan R. Jensen, M.D.Interventional CardiologistMemorial HospitalColorado Springs, Colorado

Claudia Korcarz, DVM, RDMSManager, Atherosclerosis Imaging Research ProgramUniversity of Wisconsin HospitalMadison, Wisconsin

Jack A. Ziffer, Ph.D., M.D., F.A.C.C.Chief, Department of RadiologyBaptist HospitalMedical Director, Cardiac ImagingBaptist Cardiac & Vascular InstituteMiami, Florida




Appendix B: Resources

MR Glossary of Terms and Acronyms

A standard glossary of MR terms and acronym definitions can be found on the GE Healthcare Learning System (HLS) web site at hls.gehealthcare.com. Click on the program title (in your Learning Plan or course catalog) to display the Items Details page. Open the Related Document tab and click the MR Glossary link.

Electronic Resources

American College of Radiology: http://www.acr.org

American Heart Association: http://www.americanheart .org

American Society of Nuclear Cardiology: http://www.asnc.org

American Society of Radiologic Technologists: http://www.asrt .org

American Stroke Association: http://www.strokeassociation.org

Institute for Magnetic Resonance Safety, Education, and Research: http://www.IMRSER.org

MRIsafety.com: http://www.mrisafety.com/

Radiological Society of North America: http://www.rsna.org

Section for Magnetic Resonance Technologists: http://www.ismrm.org/smrt/

Society of Nuclear Medicine: http://www.snm.org

NOTE: The Internet is an ever-evolving environment and links are subject to change without notice.




Appendix C: Post-Test

To be eligible for CE credit , you MUST view the video presentation first . Then complete the post-test on the GE Healthcare Learning System (hls.gehealthcare.com) by the due date listed online.

CT: Comparative Cardiac Imaging LMS Course Number: 3357

1. According to Dr. Douglas, the buildup of atherosclerotic plaques in arteries begins to occur before the age of _____ years. a. 5b. 10c. 15d. 20

2. It is extremely difficult to reverse atherosclerotic disease. a. Trueb. False

3. Challenges to the image quality derived from a CT coronary angiogram include _____. a. arterial stenosisb. rapid bloodflowc. significant arterial calciumd. slow heart rate

4. Men and women are both susceptible to coronary artery disease; however, in women as compared to men, heart disease may produce _____. a. different symptomsb. quicker recovery ratesc. less paind. fewer complications

5. According to Dr. DiCarli, SPECT imaging exhibits inherent limitations including _____. a. high radiation doseb. temporal resolutionc. low contrast detectabilityd. low attenuation

6. Rather than using single photon imaging as a mode of detection, as is done with SPECT, PET scanning uses a more effective method called _____ imaging. a. bi-planarb. correlativec. iteratived. coincidence

7. Patients may present with a uniform decrease in bloodflow to the heart during physical stress; this is called _____. a. myocardial infarctionb. balanced ischemiac. angina pectorisd. arrhythmia




8. According to Dr. Berger, the use of CT in combination with SPECT provides an effective _____-based imaging method. a. photonb. objectivec. attenuation correctiond. anatomically

9. Invasive cardiac catheterization studies are effective in evaluating _____. a. arterial soft plaquesb. the arterial wallc. atherosclerotic plaque stability d. the coronary artery lumen

10. The use of PET imaging can assess patients for coronary artery disease and also pinpoint areas of the heart muscle that are not contracting. a. Trueb. False

11. Hybrid PET/CT systems can very effectively indicate the extent of anatomic coronary artery disease and can also assess the ______ of/from that disease. a. mappingb. potential for complicationsc. functional significanced. final prognosis

12. The combination of CT and PET _____ the examination time needed for the PET part of the study. a. shortensb. lengthensc. have no effect ond. postpones

13. A negative perfusion study of the heart , such as SPECT or PET, does NOT rule out _____. a. functional abnormalityb. coronary artery diseasec. infarctiond. ischemia

14. The heart’s vasculature contains diagonal coronary arterial branches that arise from the _____ artery. a. right coronary b. left coronary c. circumflexd. left anterior descending

15. There are _____ primary arteries that arise from the left main coronary artery. a. twob. threec. fourd. five

16. The obtuse marginal coronary arterial branches arise from the _____ artery. a. left anterior descendingb. circumflexc. right main coronaryd. posterior descending




17. The right coronary artery arises from the _____, and its origin is located _____ than the left coronary artery’s origin. a. aorta; higherb. circumflex artery; lowerc. aorta; lowerd. posterior descending artery; higher

18. The _____ artery supplies blood to most of the inferior portion of the heart . a. left main coronary b. right coronaryc. obtuse marginald. diagonal

19. According to Ms. Comeau, when what are termed jets are seen on MRI scans of the heart , this represents valvular _____. a. prolapseb. digitizationc. regurgitationd. flutter

20. According to Dr. Korcarz, brachial reactive hyperemia studies performed with sonography are designed to evaluate reaction of the arterial _____. a. lumenb. basement membranec. adventitiad. endothelium


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