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Cardiac PET Imaging for the Detection and Monitoring of Coronary Artery Disease and Microvascular Health

Thomas H. Schindler, MD^_*,_*, Heinrich R. Schelbert, MD, PhD, Alessandra Quercioli, MD^_*, Vasken Dilsizian, MD

^_* Nuclear Cardiology and Cardiac Imaging, Division of Cardiology, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland

^_* Reprint requests and correspondence: Dr. Thomas H. Schindler, Department of Internal Medicine, Cardiovascular Center, 6th Floor, Nuclear Cardiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva, Switzerland (Email: thomas.schindler{at}hcuge.ch).

Positron emission tomography (PET) myocardial perfusion imaging in concert with tracer-kinetic modeling affords the assessment of regional myocardial blood flow (MBF) of the left ventricle in absolute terms (milliliters per gram per minute). Assessment of MBF both at rest and during various forms of vasomotor stress provides insight into early and subclinical abnormalities in coronary arterial vascular function and/or structure, noninvasively. The noninvasive evaluation and quantification of MBF and myocardial flow reserve (MFR) extend the scope of conventional myocardial perfusion imaging from detection of end-stage, advanced, and flow-limiting, epicardial coronary artery disease (CAD) to early stages of atherosclerosis or microvascular dysfunction. Recent studies have shown that impaired hyperemic MBF or MFR with PET, with or without accompanying CAD, is predictive of increased relative risk of death or progression of heart failure. Quantitative approaches that measure MBF with PET identify multivessel CAD and offer the opportunity to monitor responses to lifestyle and/or risk factor modification and to therapeutic interventions. Whether improvement or normalization of hyperemic MBF and/or the MFR will translate to improvement in long-term cardiovascular outcome remains clinically untested. In the meantime, absolute measures of MBF with PET can be used as a surrogate marker for coronary vascular health, and to monitor therapeutic interventions. Although the assessment of myocardial perfusion with PET has become an indispensable tool in cardiac research, it remains underutilized in clinical practice. Individualized, image-guided cardiovascular therapy may likely change this paradigm in the near future.

Key Words: cardiovascular disease prevention • coronary artery disease • coronary circulation • endothelium • microcirculation • myocardial blood flow • myocardial flow reserve • positron emission tomography

Abbreviations and Acronyms   CAD = coronary artery disease   CPT = cold pressor test(ing)   CT = computed tomography   MBF = myocardial blood flow   MFR = myocardial flow reserve   PET = positron emission tomography   SPECT = single-photon emission computed tomography

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