Relative uptake PET perfusion images are scaled by the color bar from 0% to 100% for maximum relative uptake (white), with red being the next highest, and color gradations from red to yellow, green, and blue indicating progressively lower relative myocardial perfusion. A generic coronary map based on arteriographic-PET correlations in over 1,000 patients is superimposed on the relative perfusion images to show arterial distributions. The arteriogram shows quantitative coronary arteriographic analysis (QCA). CFR = coronary flow reserve; DS = diameter stenosis; FFR = fractional flow reserve; LAD = left anterior descending coronary artery; LCx = left circumflex; OM1 = 1st obtuse marginal branch; OM2 = second obtuse marginal branch; PET = positron emission tomography; RI = ramus intermedius.

(A) Coronary flow reserve versus arteriographic percent diameter stenosis in canine experimental model. Adapted, with permission, from Gould et al. (1). (B) Coronary flow reserve in open-chest humans at bypass surgery versus arteriographic percent diameter stenosis. Solid or open circles or squares indicate different coronary arteries. Reproduced, with permission, from White et al. (12). RCA = right coronary artery; other abbreviations as in Figure 1.

Fractional flow reserve (FFR) by pressure wire versus percent diameter stenosis by quantitative coronary arteriogram (QCA), by quantitative coronary computed tomography (QCT) angiogram, by visually estimated coronary arteriogram (CCA), and by visually estimated coronary CT angiography (CTCA) for 50% diameter stenosis threshold. Reproduced, with permission, from Meijboom et al. (13).

(A) Schematic illustrating limitations of anatomic measures of stenosis severity by arteriogram (Artgm) or intravascular ultrasound (IVUS) due to diffuse disease with and without remodeling compared to coronary flow reserve. (B) For the schematic arteries illustrated in A, a scatter plot of coronary flow reserve (CFR) versus percent diameter stenosis (%DS) by arteriogram (brown diamonds) and by IVUS (yellow circles). The numbers beside each point of the scatter gram correspond to the numbered schematic examples of A.

Cine images of a precise stenosis phantom consisting of contras-filled channels in a plastic block immersed in water without motion, as a visual "training" reference. Abbreviation as in Figure 4.

(A) Randomized trial of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) compared to arteriographically guided PCI in 1,008 patients. Reproduced, with permission, from Tonino et al. (18). The FFR-guided group had fewer invasive procedures and a significantly lower composite end point of death, nonfatal myocardial infarction, and repeat revascularization at 1 year (p = 0.02). (B) Randomized trial of PCI compared with medical treatment in 2,287 patients with coronary stenosis that was suitable for PCI by arteriogram, showing no mortality advantage of PCI over medical treatment. Reproduced, with permission, from Boden et al. (22).

(A) Topographic 3-D displays of PET relative perfusion in 90° quadrants from left lateral, to inferior, septal (right), and anterior views, scaled as for Figure 1. (B) Absolute myocardial perfusion in cc/min/g at rest, with dipyridamole stress and CFR as scaled by the color bar for 4 x 4 pixel sample volumes throughout the left ventricle. The quantitative image is displayed in square quadrants delineated by the large square grid lines for semiautomated processing into cc/min/g or CFR. To avoid partial volume errors biasing average quadrant values, the apical region and the region of the membranous septum above the upper and lower horizontal grid lines are excluded from average quadrant values. ANT = anterior; INF = inferior; LAT = lateral; SEP = septal; other abbreviations as in Figure 1.

(A) PET relative perfusion images in 3 different patients with severe coronary artery disease. Except for the single resting baseline inferior views shown for each patient, all other quadrant views of resting relative uptake images (lateral, anterior, and septal quadrants) were normal for all 3 patients. (B) For each of the same 3 patients, CFR throughout the left ventricle is shown. Average CFR for the whole heart and average quadrant values are shown for each quadrant. Abbreviations as in Figure 1.

(A) PET relative perfusion images in 3 different patients with less severe stress-induced relative perfusion abnormalities. Except for the single resting baseline inferior views, all other quadrant views of resting relative uptake images were normal for all 3 patients. (B) Coronary flow reserve for each of the same 3 patients. Abbreviation as in Figure 1.

(A) Initial validation of absolute myocardial perfusion using rubidium-82 measured by epicardial radiation detectors compared with microspheres. Reproduced, with permission, from Goldstein et al. (33). (B) Validation of CFR measured by PET imaging of rubidium-82 using the "simple flow model" compared with the more complex complete compartmental modeling, both having comparable correlation with CFR measured by flow meter. Reproduced, with permission, from Yoshida et al. (25). Abbreviations as in Figure 1.

Cumulative events over 5-year follow-up after PET-guided management with maximal intense combined lifestyle–pharmacologic treatment compared with moderate standard lipid drug treatment and casual (poor) community practice as a nonrandomized pilot trial in 409 patients with coronary atherosclerosis. Any event includes death, nonfatal myocardial infarction, coronary bypass surgery, PCI, or stroke. Adapted, with permission, from Sdringola et al. (34). CABG = coronary artery bypass graft; HDL = high-density lipoprotein; LDL = low-density lipoprotein; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty; TC = total cholesterol; TG = triglyceride; other abbreviations as in Figures 1 and 6.

(A) Single views of stress PET relative perfusion images at baseline and follow-up of 2 different patients, illustrating progression and regression of coronary artery stenosis in the single view with a perfusion abnormality, other normal views not shown as redundant. (B) Schematic of stress PET images at baseline compared with follow-up PET in various quadrant pairings. Reproduced, with permission, from Sdringola et al. (35). Abbreviations as in Figures 1 and 3.