cardiac fdg pet requisition - University of Ottawa Heart Institute

613-696-7104
613-696-7000 ext. 14809 or
[email protected]
Submission (with documents):
Information / Questions:
PERTINENT TEST RESULTS / CONSULTS MUST ACCOMPANY THE REQUEST
*Last Name *First Name
*phone Alternative #
II
III. Pertinent Clinical Information (INDICATE 'Yes' or 'No' FOR ALL )
*DOB
(dd/mmm/yyyy)
E F Other :
Preferred language
*Age *Gender
M F
II. No
MRN
Diabetes No Pacemaker/AICD/CRT Yes NoYes Previous CABG
Previous PCI
Yes No
Yes No
A
ddressograph here
NYHA Class III IV MI in past 30 days Yes No
Inpatient Outpatient-Urgent Outpatient
Stress MRI Cardiac CTA Thoracic CT
Stress ECHO ECHO
MRI
Other Test (specify)
OHIP # Version
*MANDATORY FIELDS
I-B. SPECIAL ACCESS REQUEST
Sarcoidosis
Sarcoidosis Followup
Inflammation / Infection
(specify below)
Viability (LVEF>40%)
Aortitis
Other (specify below)
Copies to
Date
A
pproved:
Special Access Use Only
Final Approved :
FDG-PET ID: - -
*Phone #
Yes No
A
pproved
*Physician's
Signature
*Fax #
*Date
(dd/mmm/yyyy)
*Email @
Date
Received:
PET center number ID
Reviewers
Yes No
Yes No
Forward to PET Center
A
uthorized
Signature:
FDG-REQ (05Apr2017)
I-A. FDG PET VIABILITY COMPLETE SECTION I-A, II and III
Yes No
or LV Function Class III IV
Candidate for revascularization or heart transplantation Yes No
EF = %
CLINICAL INFORMATION:
*Priority
Yes No
Stress Perfusion Coronary AngioMUGA Pulmonary Testing
Moderate to severe ischemic LV dysfunction ( EF < 40%)
** All cardiac FDG PET Sarcoidosis
investigations require clinical referral to a
cardiac sarcoidosis specialist. Please indicate
Cardiac Sarcoidosis Referral Clinic of choice:
OTTAWA
TORONTO
HAMILTON
LONDON
WBC Scan
ext. ext.
COMPLETE SECTION I-B, II and III
Prior Cardiac Testing Yes Special Access requests
ATTACH REPORTS
ext.
CHECK ALL THAT APPLY
Physician Contact:
*Name (Print)
*First Name *Last Name
Imaging review
CARDIAC FDG PET
REQUISITION
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ORDERINGCARDIACFDGPET
CARDIACVIABILITYASSESSMENTistheonlycardiacapprovedindication(INSURED)forFDGPETinthe
provinceofOntario.
Yourpatientmustmeetinsuredcriteriaasfollows:
‐anEF<40%(orLVclassIIIorIV)AND
‐beacandidateforrevascularization
INSTRUCTIONS
COMPLETE:Patientinformation,allpartsofSectionI‐A,IIandIII.ProviderelevantCLINICALINFORMATIONin
theboxprovidedandensurethephysiciancontactsectioniscomplete.
Submittocardiacbookingoffice.
CARDIACSPECIALACCESSPROGRAM(SAP)
RequestsforFDGPETimagingmaybegranted,forspecificindications,viatheProvincialCardiacFDGPET
SpecialAccessprogram(UNINSURED).Suchrequestsrequiresubmissionofsupportingevidenceandreviewby
anexpertpanel.Specificcriteriafortheseindicationsmayapply(*).
SpecialAccessindicationscurrentlyinclude(butmaynotbelimitedto):
CardiacSarcoidosisandfollowup* Aortitis
DeviceInfection*ARVC,AIC*
Endocarditis*Myocarditis*
OtherInflammatoryprocesses*
ViabilityAssessmentwithEF>40(largefixeddefectonperfusionimaging)
INSTRUCTIONS
COMPLETE:Patientinformation,allpartsofSectionI‐B,IIandIII.ProviderelevantCLINICALINFORMATIONin
theboxprovidedandindicatetheSarcoidosisreferralclinicofchoice(requirement).Ensurethephysician
contactsectioniscompletetoallowSAPstafftocommunicatewiththereferringphysician.
REQUIREDATTACHMENTS:Pertinentclinicalresultsieconsult,currentmedicaltreatment,rationaleexplaining
needforFDGPET,relevantdiagnostictests(MR,CT,echo,ECG,labresults).
RequestsforFDGPETviaSpecialAccesswillnotbeprocessediftherequisitionisincompleteorsupporting
documentationisnotattached.
MoreInfo:
http://www.ccn.on.ca/ccn_public/uploadfiles/files/FDG_PET_Requisition_Package_04Apr2017.pdf
https://www.ottawaheart.ca/document/cardiac‐fdg‐pet‐requisition
https://www.ottawaheart.ca/fr/document/demande‐d%E2%80%99examen‐tep‐au‐fdg
SubmissionofSpecialAccessRequests:
CompletetherequisitionandFAXitalongwithsupportingdocumentsto:613‐696‐7104
Questions:pleasecall613‐696‐7000,ext.14809oremailusat[email protected]
Version:05Apr2017
Return to Requisition

CARDIACFDGPETSPECIALACCESSPROGRAM
Pleaseforwardquestionsorconcernstocar[email protected] VersionMarch25,2017
IndicationsforFDGPETinCARDIACSARCOIDOSIS(CS)
ALLreferralsforCardiacFDGPETimagingforcardiacsarcoidosisMUSTbeaccompaniedby
supportingdocumentationincluding,butnotlimitedtoclinicalconsults,CardiacMR,thoracic
CT,echo(TEE,TTE),labreport,ECG’s.
Patientsmustmeetpresentationcriteriaforanygivenclinicalindication
ACCEPTEDCLINICALINDICATIONPRESENTATION
1.Patientswithbiopsyprovenorclinicaldiagnosis
ofpulmonaryorsystemicsarcoidosis
AND
inwhomobstructivecoronarydiseasehasbeen
ruledout*
*Perfusion/FDGPETimagingmaynotbeableto
distinguishCSscarandinflammationfrom
hibernatingmyocardium.Thisshouldbe
consideredwhenorderingthetestandinterpreting
thefindings.
Supportingdocumentsmustincludeofpositive
biopsyorclinicalconsultdemonstratingpulmonaryor
systemicsarcoid.
ANDoneormoreabnormalinitialscreeningteststo
screenforcardiacinvolvement.
AnAbnormalscreeningtestisdefinedasoneormore
ofthefollowing:
abnormalECGdefinedascompleteleftor
rightbundlebranchblockand/orpresenceof
unexplainedpathologicalQwavesin2or
moreleads
abnormalechodefinedasRWMAand/orwall
aneurysmand/orbasalseptumthinning
and/orLVEF<50%
abnormalHolterdefinedassustainedornon‐
sustainedVT
cardiacMRIsuggestiveofcardiacsarcoid
2. Inyoungpatients(age<60years)with
unexplained,newonset,significantconduction
systemdisease,toscreenfor
CSasunderlyingetiology.
SupportingdocumentsmustincludeECGorconsult
letter.
DefinedassustainedMobitzII2nddegreeor
3rddegreeAVblock
3. Inpatientswithidiopathicsustained
ventriculartachycardia(VT),toscreenforCS
asunderlyingetiology.
SupportingdocumentsmustincludeECGorconsult
letter/clinicnotes,echo,othertests.
idiopathicVTisdefinedasVTnotfulfilling
anyoffollowingcriteria
i. TypicaloutflowtractVT
ii. FascicularVT
iii. VTsecondarytootherstructuralheart
disease(coronaryarterydisease,any
cardiomyopathyotherthanidiopathic).
4. InpatientswithprovenCStofollowresponse
totreatmentwithsteroidsand/or
immunosuppressants.
Supportingdocumentsmustinclude
documentationoftreatmenttodate,consult
letter/clinicnotes,echo,othertests.
Patientsundergoing3ormoreFDGPETscans
toassessresponsetotherapywillhavePET
scanseriesreviewedbyexpertPETreviewer
andCardiacSarcoidSpecialist.
Dietpreparation(highfat,lowcarbohydrate,lowprotein)isrequiredforoptimalimageresultsusingFDGPET.Click
hereforrequiredprep.
AsaconditionofapprovalforcardiacFDGPETinvestigationofsarcoidosis,allpatientsrequireaclinicalreferraltoa
CSspecialist,whoisalsoinvolvedwiththeMOHPETCardiacSarcoidosisRegistry.
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CARDIACFDGPETSPECIALACCESSPROGRAM
Pleaseforwardquestionsorconcernsto[email protected]
VersionMarch25,2017
INDICATIONSFORFDGPET/CTIMAGINGINTHEDETECTIONOFCARDIACINFLAMMATIONAND
INFECTION‐FDGPET/CTmaybeindicatedasanadjuvantimagingtooltoexistingstandardinstitutional
practiceandisnotmeanttoreplacestandardclinicalinvestigation.
ALLreferralsforCardiacFDGPETimagingforcardiacinfection/inflammationMUSTbeaccompanied
bysupportingevidencesuchasclinicalconsults,CardiacMR,CT,echo(TEE,TTE),labreports.
ACCEPTEDCLINICAL
INDICATION
PRESENTATION
1. InfectioninImplantable
CardiacDevicessuchas
pacemaker,ICD,CRTwhere
thereisahighclinicalsuspicion
and/orlaboratoryevidenceof
infection
Oneormoreofthefollowingissuspected:
generatorpocketinfectionwithoutendovascularleadinfection
endovascularleadinfectionwithoutgeneratorpocketinfection
generatorpocketinfectionandendovascularleadinfection
OR
Thediagnosisofinfectionhasbeenmadeandthereis:
Suspectedextra‐cardiaccomplications(i.e.septicemboli)
2. Infectiveendocarditis(using
modifiedDukecriteria)where
thereisahighclinicalsuspicion
and/orlaboratoryevidenceof
infection
Oneormoreofthefollowing:
Possibleinfectiveendocarditis
Rejectedinfectiveendocarditis(accordingtomodifiedDuke
Criteria),butclinicalsuspicionishigh
Definiteinfectiveendocarditiswith:
i) Suspicionofextra‐cardiaccomplications(i.e.septic
emboli)
ii) Suspicionofcardiaccomplications(e.g.perivalvular
abscess)
3. Pericarditis Oneormoreofthefollowing:
Persistentsymptomsdespite2weeksofadequatetherapy
Recurrentpericarditis/symptomsdespiteadequatetreatmentof
theinitialepisode
Assessresponsetotherapy4weeksaftertherapyinitiation
4. Myocarditis Oneormoreofthefollowing:
Recurrentmyocarditis/symptomsdespiteadequatetreatmentof
theinitialepisode
Lackofleftventricularfunctionrecovery
Troponinelevationoutofkeepingwiththediagnosisof
myocarditis
5. Patientswithunexplained
cardiomyopathyand
ventriculararrhythmia(ARVC,
AIC)
Ventriculararrhythmiainthesettingofunexplained
cardiomyopathy,despiteadequateinvestigation,including
referral/consultationwithanEP(electrophysiology)specialist.
6. OtherInflammatoryprocess Compellingevidencemustbeprovided.Suspicionofcardiac
inflammatoryprocessesiemultipledifferentialinflammatory
diagnosesbasedonMRI/CTimaging.3reviewersforapproval.
*Aspecialdietpreparation(highfat,lowcarbohydrate,lowprotein)isrequiredforoptimalimage
resultsusingFDGPET.Clickhereforrequiredprep.
Return to Requisition
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UOHI‐KetogenicdietpreparationforFDGPETImagingofcardiacinflammationMar25,2017
UniversityofOttawaHeartInstituteKetogenicdiet(highfat,highprotein,lowcarbohydrate)
preparationforFDGPETImagingofcardiacinflammation
TheKetogenicdietisahighfat,highprotein,andlowcarbohydratedietthatyouneedtofollowforoneday
beforeyourscan.Followingthisdietwillhelpimprovetheimagingpicturesobtainedfromyourscan.The
Ketogenicdietissafetofollowandisapprovedforuseforonedayaspreparationforthescan.
WhydoIneedtochangemydietthedaybeforethescan?
Thepurposeofthescanistofindabnormalareasinyourheart.Themusclecellsoftheheartabsorbanduse
glucose(sugar)forenergy.ThePETimagingscanusesFluorodeoxglucose(FDG),asugarbasedtracer.Whenwe
injectFDG,normalhealthyheartmusclecellswillabsorbFDGbecauseitisasugar.FDGPETimagingallowsthe
doctorstoseeareasoftheheartthatarenormalorabnormal.
Incertainconditions,suchassarcoidosisorotherinflammatoryconditions,wedonotwantthenormalheart
musclecellstoabsorbtheFDGbecauseitinterfereswiththeimagingpictures.Theketogenicdiethelpsensure
highqualityimagesbecausethehighfatcontentofthedietforcesthebodytochoosefatsforfuelandenergy
ratherthancarbohydrates(sugars).Therefore,thenormalcellsare‘tricked’intousingfatasenergyandtheFDG
isnotabsorbed.Asaresult,onlytheabnormalareasoftheheartareseen.
Tofollowtheketogenicdiet,youmustchoosehighfatandproteinfoodsandavoidcarbohydratefoodsforthe
entiredaybeforeyourscan.Highfatandproteinfoodsincludemeat,fattyfishsuchassalmonandtuna,eggs,
vegetableoil,margarine,andbutter.Carbohydrate(sugar)isfoundinallgrains,starchyvegetables,allfruitand
dairyproducts.Wehaveprovidedasamplemenuandfoodchoicesbelowtohelpyouwithyourfoodchoices.
Ifyouhavediabetes,pleasecontactyourdiabetesdoctorornurse.Yourdiabetesmedicationsand/orinsulinwill
needtobeadjustedsoyoudonotgetlowbloodsugarswhilefollowingthisdiet.Thisdietisonlyforonedayand
yourdiabetescanbemanagedwhileyoufollowthediet.
Inadditiontofollowingtheketogenicdiet,youmustalsoavoidstrenuousexercisethedaybeforeyourscan.You
mustnoteatordrinkanything(exceptwater)beforethescan.Itisimportantthatyoudrinktwotothree‐12
ounce(355ml)glassesofwaterthroughthedaytostayadequatelyhydrated.
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