Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Attenuation artifact in SPECT radionuclide myocardial perfusion imaging

Gary V Heller, MD, PhD, FACC, MASNC
Section Editor
Warren J Manning, MD
Deputy Editor
Brian C Downey, MD, FACC


The value of radionuclide myocardial perfusion imaging (rMPI) with single-photon emission computed tomography (SPECT) for the diagnosis and risk stratification of coronary heart disease (CHD) is well-established. However, the full clinical potential of rMPI has not been realized due to numerous factors producing artifacts. These artifacts degrade image quality and increase the risk of misinterpretation of the results [1].

Soft tissue attenuation is one of the more common causes of rMPI artifact. The heart is surrounded by tissues of varying densities (eg, bone, lungs, and breast). Radionuclide imaging of the thorax results in nonuniform myocardial photon activity due to these intervening structures. Unpredictable artifact may arise when the body habitus differs significantly from expected gender-specific patterns. Photon attenuation and the resultant artifacts are affected by several factors, including:

Body size

Depth of the heart in the body


To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jun 30, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Singh B, Bateman TM, Case JA, Heller G. Attenuation artifact, attenuation correction, and the future of myocardial perfusion SPECT. J Nucl Cardiol 2007; 14:153.
  2. Picano E, Bedetti G, Varga A, Cseh E. The comparable diagnostic accuracies of dobutamine-stress and dipyridamole-stress echocardiographies: a meta-analysis. Coron Artery Dis 2000; 11:151.
  3. Kim C, Kwok YS, Heagerty P, Redberg R. Pharmacologic stress testing for coronary disease diagnosis: A meta-analysis. Am Heart J 2001; 142:934.
  4. Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS. Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance. JAMA 1998; 280:913.
  5. Johnstone, D, Wackers, et al. Effect of patient positioning on left lateral thallium-201 myocardial images. J Nucl Med 1979; 20:183.
  6. Wackers, F . Diagnostic pitfalls of myocardial perfusion imaging in women. J Myocard Ischemia 1992; 4:23.
  7. Manglos SH, Thomas FD, Gagne GM, Hellwig BJ. Phantom study of breast tissue attenuation in myocardial imaging. J Nucl Med 1993; 34:992.
  8. DePuey EG, Garcia EV. Optimal specificity of thallium-201 SPECT through recognition of imaging artifacts. J Nucl Med 1989; 30:441.
  9. Germano G, Chua T, Kiat H, et al. A quantitative phantom analysis of artifacts due to hepatic activity in technetium-99m myocardial perfusion SPECT studies. J Nucl Med 1994; 35:356.
  10. Nuyts J, Dupont P, Van den Maegdenbergh V, et al. A study of the liver-heart artifact in emission tomography. J Nucl Med 1995; 36:133.
  11. Holly TA, Satran A, Bromet DS, et al. The impact of adjunctive adenosine infusion during exercise myocardial perfusion imaging: Results of the Both Exercise and Adenosine Stress Test (BEAST) trial. J Nucl Cardiol 2003; 10:291.
  12. Pennell DJ, Mavrogeni SI, Forbat SM, et al. Adenosine combined with dynamic exercise for myocardial perfusion imaging. J Am Coll Cardiol 1995; 25:1300.
  13. Hansen CL, Woodhouse S, Kramer M. Effect of patient obesity on the accuracy of thallium-201 myocardial perfusion imaging. Am J Cardiol 2000; 85:749.
  14. Hendel RC, Gibbons RJ, Bateman TM. Use of rotating (cine) planar projection images in the interpretation of a tomographic myocardial perfusion study. J Nucl Cardiol 1999; 6:234.
  15. Eisner RL, Tamas MJ, Cloninger K, et al. Normal SPECT thallium-201 bull's-eye display: gender differences. J Nucl Med 1988; 29:1901.
  16. Wackers FJ. Artifacts in planar and SPECT myocardial perfusion imaging. Am J Card Imaging 1992; 6:42.
  17. Bateman TM, Kolobrodov VV, Vasin AP, O'Keefe JH Jr. Extended acquisition for minimizing attenuation artifact in SPECT cardiac perfusion imaging. J Nucl Med 1994; 35:625.
  18. Wang SJ, Chen YT, Hwang CL, et al. 99mTc-sestamibi can improve the inferior attenuation of TL-201 myocardial spect imaging. Int J Card Imaging 1993; 9:87.
  19. Kiat H, Van Train KF, Friedman JD, et al. Quantitative stress-redistribution thallium-201 SPECT using prone imaging: methodologic development and validation. J Nucl Med 1992; 33:1509.
  20. Hayes SW, De Lorenzo A, Hachamovitch R, et al. Prognostic implications of combined prone and supine acquisitions in patients with equivocal or abnormal supine myocardial perfusion SPECT. J Nucl Med 2003; 44:1633.
  21. Segall GM, Davis MJ. Prone versus supine thallium myocardial SPECT: a method to decrease artifactual inferior wall defects. J Nucl Med 1989; 30:548.
  22. DePuey EG, Rozanski A. Using gated technetium-99m-sestamibi SPECT to characterize fixed myocardial defects as infarct or artifact. J Nucl Med 1995; 36:952.
  23. Smanio PE, Watson DD, Segalla DL, et al. Value of gating of technetium-99m sestamibi single-photon emission computed tomographic imaging. J Am Coll Cardiol 1997; 30:1687.
  24. Travin MI, Heller GV, Johnson LL, et al. The prognostic value of ECG-gated SPECT imaging in patients undergoing stress Tc-99m sestamibi myocardial perfusion imaging. J Nucl Cardiol 2004; 11:253.
  25. Miles J, Cullom SJ, Case JA. An introduction to attenuation correction. J Nucl Cardiol 1999; 6:449.
  26. Zaidi H, Hasegawa B. Determination of the attenuation map in emission tomography. J Nucl Med 2003; 44:291.
  27. King MA, Tsui BM, Pan TS. Attenuation compensation for cardiac single-photon emission computed tomographic imaging: Part 1. Impact of attenuation and methods of estimating attenuation maps. J Nucl Cardiol 1995; 2:513.
  28. King MA, Tsui BM, Pan TS, et al. Attenuation compensation for cardiac single-photon emission computed tomographic imaging: Part 2. Attenuation compensation algorithms. J Nucl Cardiol 1996; 3:55.
  29. Tan P, Bailey DL, Meikle SR, et al. A scanning line source for simultaneous emission and transmission measurements in SPECT. J Nucl Med 1993; 34:1752.
  30. Fleming JS. A technique for using CT images in attenuation correction and quantification in SPECT. Nucl Med Commun 1989; 10:83.
  31. Takahashi Y, Murase K, Higashino H, et al. Attenuation correction of myocardial SPECT images with X-ray CT: effects of registration errors between X-ray CT and SPECT. Ann Nucl Med 2002; 16:431.
  32. Tonge CM, Manoharan M, Lawson RS, et al. Attenuation correction of myocardial SPECT studies using low resolution computed tomography images. Nucl Med Commun 2005; 26:231.
  33. Kashiwagi T, Yutani K, Fukuchi M, et al. Correction of nonuniform attenuation and image fusion in SPECT imaging by means of separate X-ray CT. Ann Nucl Med 2002; 16:255.
  34. Ficaro EP, Fessler JA, Shreve PD, et al. Simultaneous transmission/emission myocardial perfusion tomography. Diagnostic accuracy of attenuation-corrected 99mTc-sestamibi single-photon emission computed tomography. Circulation 1996; 93:463.
  35. Kluge R, Sattler B, Seese A, Knapp WH. Attenuation correction by simultaneous emission-transmission myocardial single-photon emission tomography using a technetium-99m-labelled radiotracer: impact on diagnostic accuracy. Eur J Nucl Med 1997; 24:1107.
  36. Gallowitsch HJ, Sykora J, Mikosch P, et al. Attenuation-corrected thallium-201 single-photon emission tomography using a gadolinium-153 moving line source: clinical value and the impact of attenuation correction on the extent and severity of perfusion abnormalities. Eur J Nucl Med 1998; 25:220.
  37. Hendel RC, Berman DS, Cullom SJ, et al. Multicenter clinical trial to evaluate the efficacy of correction for photon attenuation and scatter in SPECT myocardial perfusion imaging. Circulation 1999; 99:2742.
  38. Grossman GB, Garcia EV, Bateman TM, et al. Quantitative Tc-99m sestamibi attenuation-corrected SPECT: development and multicenter trial validation of myocardial perfusion stress gender-independent normal database in an obese population. J Nucl Cardiol 2004; 11:263.
  39. Thompson RC, Heller GV, Johnson LL, et al. Value of attenuation correction on ECG-gated SPECT myocardial perfusion imaging related to body mass index. J Nucl Cardiol 2005; 12:195.
  40. Hendel RC, Corbett JR, Cullom SJ, et al. The value and practice of attenuation correction for myocardial perfusion SPECT imaging: a joint position statement from the American Society of Nuclear Cardiology and the Society of Nuclear Medicine. J Nucl Cardiol 2002; 9:135.
  41. Links JM, DePuey EG, Taillefer R, Becker LC. Attenuation correction and gating synergistically improve the diagnostic accuracy of myocardial perfusion SPECT. J Nucl Cardiol 2002; 9:183.
  42. Gibson PB, Demus D, Noto R, et al. Low event rate for stress-only perfusion imaging in patients evaluated for chest pain. J Am Coll Cardiol 2002; 39:999.
  43. Noble GL, Ahlberg AW, Kokkirala AR, et al. Validation of attenuation correction using transmission truncation compensation with a small field of view dedicated cardiac SPECT camera system. J Nucl Cardiol 2009; 16:222.
  44. Heller GV, Bateman TM, Johnson LL, et al. Clinical value of attenuation correction in stress-only Tc-99m sestamibi SPECT imaging. J Nucl Cardiol 2004; 11:273.
  45. Baghdasarian SB, Noble GL, Ahlberg AW, et al. Risk stratification with attenuation corrected stress Tc-99m sestamibi SPECT myocardial perfusion imaging in the absence of ECG-gating due to arrhythmias. J Nucl Cardiol 2009; 16:533.
  46. Cerqueira MD, Allman KC, Ficaro EP, et al. Recommendations for reducing radiation exposure in myocardial perfusion imaging. J Nucl Cardiol 2010; 17:709.
  47. Mathur S, Heller GV, Bateman T, et al. Clinical outcomes in patients undergoing attenuation correction stress-only Tc99m gated SPECT myocardial perfusion imaging for evaluation of coronary artery disease. J Nucl Med 2010; 51:208.
  48. Des Prez, et al. ASNC Clinical Update: Stress-only myocardial perfusion imaging. J Nucl Cardiol 2009.
  49. Bhavnani SP, Heller GV. Stress-only myocardial perfusion imaging … it is time for a change! J Nucl Cardiol 2011; 18:836.