Artifactual reverse distribution pattern in myocardial perfusion SPECT with technetium-99m sestamibi

Background. The reverse distribution pattern (RDP), in which resting perfusion imaging demonstrates a de novo or more marked regional defect than that present in stress images, is observed frequently in patients,vith a low likelihood of coronary artery disease. Methods and Results, To determine whether this scan pattern is artifactual and to investigate its causes, we retrospectively evaluated scans in 202 patients with a low likelihood of coronary artery disease (77 men and 125 women) undergoing single-day rest/stress technetium-99m sestamibi single photon emission computed tomography (SPECT), The presence and location of RDP was correlated with relevant body habitus parameters. RDP was observed in 15.3% of patients. The finding was significantly more frequent in patients who were obese (P <.02 in men, P <.03 in women), in men with abdominal protuberance (P <.05), and in women with prominent breast "shadows" observed on planar projection images (P <.008), RDP was most frequent in the right coronary artery territory in men and the left anterior descending coronary artery territory in women. It was demonstrated by means of a cardiac SPECT phantom experiment that soft tissue attenuation effects were most evident in low count density SPECT studies with localized soft tissue attenuation, accounting for the higher than clinical observation of RDP in obese patients undergoing low-dose rest/high-dose imaging. Conclusions. RDP is a frequently encountered artifact in obese patients undergoing rest/stress Tc-99m sestamibi SPECT, particularly in men with abdominal protuberance and in women with large, dense breasts.