Clinical application of cardiac scintigraphy with bone tracers: controversies and pitfalls in cardiac amyloidosis

Abstract

Cardiac amyloidosis (CA) is a life-threatening disease caused by extracellular deposition of amyloidogenic proteins in the heart tissue; it could be associated with a poor prognosis and remains underdiagnosed and underestimated. During the last years, bone scintigraphy has been widely used to facilitate the diagnosis of CA, avoid endomyocardial biopsy, and differentiate amyloid light-chain amyloidosis from transthyretin amyloidosis. Technetium-99m pyrophosphate (^99mTc-PYP) is the most used tracer in the United States, but a standardized and shared acquisition protocol is still lacking; technetium-99m 3,3-diphosphono-1,2-propanodicarboxylic acid (^99mTc-DPD) is widely used in Europe and can count on a more grounded data than ^99mTc-PYP. Both tracers suffer from some diagnostic limitations (due to their biochemical characteristics) and pitfalls that can lead to a misdiagnosis of CA. We aim to briefly describe the main differences between ^99mTc-PYP and ^99mTc-DPD, analyzing the data available in the literature and highlighting the most frequent causes of misdiagnosis and pitfalls. Both ^99mTc-DPD and ^99mTc-PYP show good accuracy for the diagnosis of CA with high specificity and sensibility. Nevertheless, to achieve this accuracy, the correct acquisition protocols must be followed for each tracer, as suggested in the latest recommendation. Proper diagnosis of CA has a crucial role in patient management; therefore, it is important for nuclear physicians to have the most specific approaches in acquiring and interpreting bone scintigraphy for transthyretin cardiac amyloidosis.

Keywords

Cardiac amyloidosis / ^99mTc-PYP / ^99mTc-DPD / bone scintigraphy / nuclear medicine

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