LAUSR

The working group of Nuclear Cardiology from the Spanish Society of Nuclear Medicine and Molecular Image (SEMNIM) wish to expose some comments and observations about the paper from J.A. Virizuela et al. [1]. In this paper, they affirm “baseline echocardiography, in patients at risk for heart failure (HF), helps to optimize CV therapy” and also they establish “echocardiography is deemed the technique of choice when undertaking a global comprehensive assessment of cardiac structure and function at baseline and during the cancer process. In patients with poor image quality, cardiac magnetic resonance is the best option to avoid radiation associated with nuclear medicine techniques”. The echocardiography is the most used technique in cardiology. However, the 2D echocardiography does not provide the optimal conditions to diagnosing and following. The 3D echocardiography and strain are considered the most appropriate, but these techniques are not always available because of the equipment, or the specialist that perform it, as the authors indicate in this paper. There is not enough evidence about its use in cardiotoxicity [2, 3]. On the other hand, they propose the CMR (cardiovascular magnetic resonance) in case of a poor image echocardiography resolution. It is known that CMR is most expensive, uncomfortable for the patient, and with a low disponibility, and also have no evidence for cardiotoxicity. All these features have been recognized in other studies from the same authors, and also they establish that CMR is not a choice in the actual clinical practice for these patients. They assign to the CNM (Cardiac Nuclear Medicine) techniques an unjustified risk using ionizing radiation [2, 3]. There is a solid evidence about the use of ERNA (equilibrium radionuclide angiocardiography) in the assessment of chemotherapy cardiotoxicity [4, 5], with a high reproducibility and less intraand interobserver variations, less than echocardiography, becoming the ideal technique to assess and follow the small changes of LVEF (left ventricular ejection fraction) FEVI as it is required in this group of patients. There are other advantages in using ERNA as a not geometric method for calculating LVEF FEVI. There is no miscalculation due to changes in regional ventricular motility and morphology. This can be used in all patients with obesity, breast prostheses, claustrophobic, renal insufficiency, and pacemakers [6]. This method is a low cost and highly available study, feasible in all nuclear medicine services. In the recent paper from Doherty et al. about the appropriate use of image techniques, it was a consensus between ten Scientific Societies [7] and they established that in the initial assessment of patients initiating or have already received chemotherapy, the 3D echocardiography, strain, and ERNA have higher scores than CMR and other techniques. About de Radiation risks of ERNA, the effective dose is very low (3–6 mSv). Thoracic or abdominal TC with IV contrast gives an effective dose from 8 to 10 mSv [8], and these methods are used in a habitual way to diagnose and reevaluate the treatment response in oncological patients. New developments allow reducing the effective dose given to the patients as in CNM explorations also TC explorations. There are no data of induced cancer from radiation exposure in CNM [9]. The effective dose given to the patient in ERNA is equivalent a dose from the ambiance for * F. J. de Haro-del Moral [email protected]