Targeting the vulnerable plaque: the evolving role of nuclear imaging

Multimodality cardiac imaging in the 21st century: evolution, advances and future opportunities for innovation

Cardiovascular imaging has significantly evolved since the turn of the century. Progress in the last two decades has been marked by advances in every modality used to image the heart, including echocardiography, cardiac magnetic resonance, cardiac CT and nuclear cardiology. There has also been a dramatic increase in hybrid and fusion modalities that leverage the unique capabilities of two imaging techniques simultaneously, as well as the incorporation of artificial intelligence and machine learning into the clinical workflow. These advances in non-invasive cardiac imaging have guided patient management and improved clinical outcomes. The technological developments of the past 20 years have also given rise to new imaging subspecialities and increased the demand for dedicated cardiac imagers who are cross-trained in multiple modalities. This state-of-the-art review summarizes the evolution of multimodality cardiac imaging in the 21st century and highlights opportunities for future innovation.

Preclinical models of atherosclerosis. The future of Hybrid PET/MR technology for the early detection of vulnerable plaque

Cardiovascular diseases are the leading cause of death in developed countries. The aetiology is currently multifactorial, thus making them very difficult to prevent. Preclinical models of atherothrombotic diseases, including vulnerable plaque-associated complications, are now providing significant insights into pathologies like atherosclerosis, and in combination with the most recent advances in new non-invasive imaging technologies, they have become essential tools to evaluate new therapeutic strategies, with which can forecast and prevent plaque rupture. Positron emission tomography (PET)/computed tomography imaging is currently used for plaque visualisation in clinical and pre-clinical cardiovascular research, albeit with significant limitations. However, the combination of PET and magnetic resonance imaging (MRI) technologies is still the best option available today, as combined PET/MRI scans provide simultaneous data acquisition together with high quality anatomical information, sensitivity and lower radiation exposure for the patient. The coming years may represent a new era for the implementation of PET/MRI in clinical practice, but first, clinically efficient attenuation correction algorithms and research towards multimodal reagents and safety issues should be validated at the preclinical level.

Delayed time-point 18F-FDG PET CT imaging enhances assessment of atherosclerotic plaque inflammation

OBJECTIVE

The aim of this study was to determine the ideal circulation time of fluorine-18 fluorodeoxyglucose (F-FDG) in order to detect and quantify atherosclerotic plaque inflammation with PET computed tomography (CT) imaging.

METHODS

Fifteen patients underwent multiple time-point imaging at ∼60, 120, and 180 min after F-FDG administration. For each time point, global assessment of aortic and carotid F-FDG uptake was determined qualitatively by visual assessment and semiquantitatively by calculation of the mean and maximum standardized uptake values (SUV) and the corresponding target-to-background ratio (TBR).

RESULTS

Delayed imaging achieved significant improvement in visualization of atherosclerotic plaque inflammation [Friedman's χ statistic (d.f.=2, n=15)=24.13, P<0.001, Kendall's W=0.80]. This observation was confirmed by semiquantitative image analysis. At 1 h, the aortic and carotid SUVmean-calculated TBR was 1.05 [95% confidence interval (CI)=0.98, 1.11] and 0.88 (95% CI=0.81, 0.96), respectively. At 3 h, the TBR significantly increased to 1.57 (95% CI=1.28, 1.86; P=0.001) for the aorta and to 1.61 (95% CI=1.36, 1.87; P<0.001) for the carotid arteries. SUVmax-calculated TBRs showed a similar increase over time.

CONCLUSION

One- and 2-h F-FDG PET CT imaging is suboptimal for global assessment of atherosclerotic plaque inflammation compared with imaging at 3 h. Our data support the utilization of 3-h delayed imaging to obtain optimal data for the detection and quantification of atherosclerotic plaque inflammation in human arteries.

Collagen-specific peptide conjugated HDL nanoparticles as MRI contrast agent to evaluate compositional changes in atherosclerotic plaque regression

OBJECTIVES

This study sought to develop magnetic resonance contrast agents based on high-density lipoprotein (HDL) nanoparticles to noninvasively visualize intraplaque macrophages and collagen content in mouse atherosclerotic plaques.

BACKGROUND

Macrophages and collagen are important intraplaque components that play central roles in plaque progression and/or regression. In a Reversa mouse model, plaque regression with compositional changes (from high macrophage, low collagen to low macrophage, high collagen) can be induced.

METHODS

This study labeled HDL nanoparticles with amphiphilic gadolinium chelates to enable target-specific imaging of intraplaque macrophages. To render HDL nanoparticles specific for the extracellular matrix, labeled HDL nanoparticles were functionalized with collagen-specific EP3533 peptides (EP3533-HDL) via poly(ethylene glycol) spacers embedded in the HDL lipid layers. The association of nanoparticles with collagen was examined in vitro by optical methods. The in vivo magnetic resonance efficacy of these nanoparticles was evaluated in a Reversa mouse model of atherosclerosis regression. Ex vivo confocal microscopy was applied to corroborate the in vivo findings and to evaluate the fate of the different HDL nanoparticles.

RESULTS

All nanoparticles had similar sizes (10 ± 2 nm) and longitudinal relaxivity r1 (9 ± 1 s(-1) mmol/l(-1)). EP3533-HDL showed strong association with collagen in vitro. After 28 days of plaque regression in Reversa mice, EP3533-HDL showed significantly increased (p < 0.05) in vivo magnetic resonance signal in aortic vessel walls (normalized enhancement ratio [NERw] = 85 ± 25%; change of contrast-to-noise ratio [ΔCNRw] = 17 ± 5) compared with HDL (NERw = -7 ± 23%; ΔCNRw = -2 ± 4) and nonspecific control EP3612-HDL (NERw = 4 ± 24%; ΔCNRw = 1 ± 6) at 24 h after injection. Ex vivo confocal images revealed the colocalization of EP3533-HDL with collagen. Immunohistostaining analysis confirmed the changes of collagen and macrophage contents in the aortic vessel walls after regression.

CONCLUSIONS

This study shows that the HDL nanoparticle platform can be modified to monitor in vivo plaque compositional changes in a regression environment, which will facilitate understanding plaque regression and the search for therapeutic interventions.

Role of Global Disease Assessment by Combined PET-CT-MR Imaging in Examining Cardiovascular Disease

Atherosclerosis is considered a chronic inflammatory disease, and thereafter the degree of this pathologic process is considered to be a major determinant in plaque stability and in forecasting future events. Over the past decade, (18)F-fluorodeoxyglucose PET/computed tomography has become a well-established imaging modality in evaluating various inflammatory disorders, and has been shown to be very useful in evaluating plaque activity in major arteries. This emerging noninvasive imaging modality has great potential in evaluating plaque vulnerability and in predicting the risk of future rupture and consequent thrombosis.

Triacylglycerol-induced impairment in mitochondrial biogenesis and function in J774.2 and mouse peritoneal macrophage foam cells

The aim of this study was to detect mitochondrial alterations in J774.2 macrophages and mouse peritoneal macrophages (MPM) foam cells. J774.2 and MPM cells were exposed to triacylglycerol (TG) emulsion (1 mg/ml) for induction of fat accumulation. Impairment of mitochondrial function was reflected by reduced cellular ATP production and decreased expression of subunits of mitochondrial complexes I and III. The expression of subunit IV of complex IV remained unchanged, however, the content of its precursor in cells increased. Inhibitors of mitochondrial complexes, rotenone (0.1 microM) and myxothiazol (25 nM), protected the viability in TG-loaded macrophages. The exposure to TG caused downregulation of PPARgamma coactivator (PGC)-1alpha and nuclear respiratory factor (NRF)-1. Activation of peroxisome proliferator-activated receptors attenuated reactive oxygen species production in the foam cells. Treatment with antioxidant N-acetylcysteine (NAC) prevented lipid-mediated mitochondrial and cellular damage. In conclusion, this study demonstrates the important role of mitochondrial biogenesis dysfunction in TG-induced lipotoxicity in macrophages.

In vivo imaging of the effect of LPS on arterial endothelial cells: molecular imaging of heat shock protein 60 expression

Bacterial endotoxins are known as stress factors for endothelial cells. In 20 normocholesterolemic New Zealand White (NZW) rabbits, endothelial stress was induced by intravenous (i.v.) injection of lipopolysaccharide (LPS), while eight NZW rabbits were sham-treated or served as untreated controls. In vivo molecular imaging was performed using co-registered computer tomography and positron emission tomography 24 h after i.v. injection of (124)I-labeled monoclonal anti-HSP60 or (124)I-radiolabelled isotype control antibodies. Compared to control animals, in vivo images of rabbit aortae revealed significantly increased endothelial binding of (124)I-labeled anti-HSP60 antibodies upon LPS, especially at sites of aortal branching. This was confirmed by immunohistochemistry and autoradiography data. Our results showed, as proof-of-principle, that HSP60-expression in normocholesterolemic rabbits is significantly increased after induction of endothelial stress and that non-invasive in vivo molecular imaging of early aortal HSP60-expression using (124)I-labeled anti-HSP60 monoclonal antibodies is possible.

In vivo molecular imaging of vascular stress

Noninvasive in vivo imaging is an emerging specialty in experimental radiology aiming at developing hardware and appropriate contrast agents to visualize the molecular basis and pathophysiological processes of many pathological conditions, including atherosclerosis. The list of potentially useful tracers and targets for in vivo molecular imaging in the cascade of early atherosclerotic events has been narrowed down to some very promising endothelial factors, i.e., cell adhesion molecules, macrophages, apoptosis, lipoproteins, heat shock proteins, and others. In this review, we will update on the progress of recent developments in the field of noninvasive molecular imaging in experimental atherosclerosis.

Lipotoxic effects of triacylglycerols in J774.2 macrophages

OBJECTIVE

Triacylglycerols (TGs) are being considered as an independent risk factor in atherosclerosis and metabolic syndrome, acting by dysregulation of the TG/high-density lipoprotein axis. Accumulation of lipids in subendothelial space attracts macrophages, leading to atherosclerotic plaque formation and increased plaque instability due to formation of foam cells and macrophage death. The aim of this study was to evaluate lipotoxic effects in macrophages caused by TG uptake.

METHODS

J774.2 macrophages were exposed to soybean or olive oil-based lipid emulsions as a source of TGs (1 mg/mL) in a presence or absence of lipase inhibitor paraoxon (20 microM) or to bovine serum albumin-complexed palmitic (150 microM), linoleic (600 microM), and oleic (600 microM) fatty acids.

RESULTS

The results demonstrated accumulation of TGs, G1/S arrest, and cell death with necrotic morphologic features after exposure to TG emulsions. These effects were prevented by treatment with an antioxidant N-acetyl-cysteine (0.5 mM). Paraoxon inhibited intracellular TG degradation but did not prevent lipotoxicity and cell death. Olive oil TG triggered macrophage death in a manner similar to soybean oil. Treatment of the macrophages with free fatty acid, mainly with palmitic acid, showed a reactive oxygen species-independent cell death pathway, which was different from that of TG and was not prevented by N-acetyl-cysteine.

CONCLUSION

This study shows a direct lipotoxic pathway for TG molecules in macrophages, which is not associated with degradation of TG molecule to free fatty acids. This study for the first time can explain at a cellular level how TGs as an independent risk factor aggravate atherosclerotic outcomes.

Localization to atherosclerotic plaque and biodistribution of biochemically derivatized superparamagnetic iron oxide nanoparticles (SPIONs) contrast particles for magnetic resonance imaging (MRI)

Annexin V recognizes apoptotic cells by specific molecular interaction with phosphatidyl serine, a lipid that is normally sequestered in the inner leaflet of the cell membrane, but is translocated to the outer leaflet in apoptotic cells, such as foam cells of atherosclerotic plaque. Annexin V could potentially deliver carried materials (such as superparamagnetic contrast agents for magnetic resonance imaging) to sites containing apoptotic cells, such as high grade atherosclerotic lesions, so we administered biochemically-derivatized (annexin V) superparmagnetic iron oxide particles (SPIONs) parenterally to two related rabbit models of human atherosclerosis. We observe development of negative magnetic resonance imaging (MRI) contrast in atheromatous lesions and but not in healthy artery. Vascular targeting by annexin V SPIONs is atheroma-specific (i.e., does not occur in healthy control rabbits) and requires active annexin V decorating the SPION surface. Targeted SPIONs produce negative contrast at doses that are 2,000-fold lower than reported for non-specific atheroma uptake of untargeted superparamagnetic nanoparticles in plaque in the same animal model. Occlusive and mural plaques are differentiable. While most of the dose accumulates in liver, spleen, kidneys and bladder, annexin V SPIONs also partition rapidly and deeply into early apoptotic foamy macrophages in plaque. Contrast in plaque decays within 2 months, allowing MRI images to be replicated with a subsequent, identical dose of annexin V SPIONs. Thus, biologically targeted superparamagnetic contrast agents can contribute to non-invasive evaluation of cardiovascular lesions by simultaneously extracting morphological and biochemical data from them.

The role of periadventitial fat in atherosclerosis

CONTEXT

It has become increasingly evident that adipose tissue is a multifunctional organ that produces and secretes multiple paracrine and endocrine factors. Research into obesity, insulin resistance, and diabetes has identified a proinflammatory state associated with obesity. Substantial differences between subcutaneous and omental fat have been noted, including the fact that omental fat produces relatively more inflammatory cytokines. Periadventitial fat, as a specific adipose tissue subset, has been overlooked in the field of atherosclerosis despite its potential diagnostic and therapeutic implications.

OBJECTIVE

To review (1) evidence for the role of adventitial and periadventitial fat in vessel remodeling after injury, (2) the relationship between adventitial inflammation and atherosclerosis, (3) the association between periadventitial fat and plaque inflammation, and (4) the diagnostic and therapeutic implications of these roles and relationships for the progression of atherosclerosis.

DATA SOURCES

We present new data showing greater uptake of iron, administered in the form of superparamagnetic iron oxide, in the periadventitial fat of atherosclerotic mice than in control mice. In addition, macrophage density in the periadventitial fat of lipid-rich plaques is increased compared with fibrocalcific plaques.

CONCLUSIONS

There is a striking paucity of data on the relationship between the periadventitial fat of coronary arteries and atherosclerosis. Greater insight into this relationship might be instrumental in making strides into the pathophysiology, diagnosis, and treatment of coronary artery disease.

Comparison of 99mTc-annexin A5 with 18F-FDG for the detection of atherosclerosis in ApoE-/- mice

PURPOSE

(99m)Tc-annexin A5, a marker of ongoing apoptosis, and (18)F-FDG, a marker of the increased metabolism of inflammatory cells, are supposed to be useful in the detection of metabolically active atheroma. This study reports a comparison of the intralesional distribution of these tracers in relation to lesion development in ApoE-/- mice.

METHODS

Male ApoE-/- mice (n = 12-14/group) were maintained on a Western-type diet after the age of 5 weeks. At 25 weeks, (99m)Tc-annexin A5 or (18)F-FDG was injected and the aortas were harvested for autoradiography (ARG) and Oil Red O staining. Regional radioactivity accumulation was compared in relation to the Oil Red O staining score (ranging from 0 to 3, a semiquantitative parameter for evaluating lesion development).

RESULTS

Both (99m)Tc-annexin A5 and (18)F-FDG showed preferential uptake into atherosclerotic lesions, with higher uptake levels for (18)F-FDG (mean, 56.07 %IDxkg/m(2)) than for (99m)Tc-annexin A5 (mean, 10.38 %IDxkg/m(2)). The regional uptake levels of each tracer correlated with the Oil Red O staining score (r = 0.65, p < 0.05 for (99m)Tc-annexin A5; r = 0.56, p < 0.05 for (18)F-FDG). The uptake ratios of advanced lesions (score >0.5) to early lesions (score <0.5) were significantly higher for (99m)Tc-annexin A5 than for (18)F-FDG (f = 4.73, p = 0.03).

CONCLUSION

Both (99m)Tc-annexin A5 and (18)F-FDG accumulate in atherosclerotic lesions and correlate with the severity of each lesion. The higher absolute uptake levels of (18)F-FDG may be advantageous for lesion detection, whereas the preferential uptake of (99m)Tc-annexin A5 in advanced lesions may be a useful indicator of late-stage lesions or vulnerable plaque transformation.

The aging of the heart and blood vessels: a consideration of anatomy and physiology in the era of computed tomography, magnetic resonance imaging, and positron emission tomographic imaging methods with special consideration of atherogenesis

Physicians have long told their patients that the doctor's job is to help patients "get as old as they can." As physicians, we have been aided in this objective by many other scientists in other disciplines. The entity of aging and its related changes blends imperceptibly with a variety of age-related diseases. However, these entities do appear to be separate though interrelated. Curing disease is important and a goal that we all work toward to add years to life expectancy. Here, we consider aging as it affects the heart and great vessels and as it serves to influence and support, if not cause, age-related cardiac diseases. This relationship is drawn as cardiac mechanics, hemodynamics, perfusion, metabolism and innervation, anatomy, and pathophysiology are each considered. The effects of aging are presented in 2 sections related to the early and recent "spikes" in aging related information. The latter is largely based in recent developments in chemistry, genetic engineering, molecular biology and the new imaging methods. The purpose of this manuscript is to present these new imaging methods, especially PET, and their impact on the second "spike." This is emphasized particularly in the second half of this review. As a method of demonstrating these imaging tools and their finest potential application, we decided to "showcase" atherosclerosis as the age-related disease for which these methods have made their greatest impact, for which yet more is promised, and for which the influence on longevity is most obvious. The application of positron emission tomography and other imaging methods to the characterization and image identification of atherosclerotic plaques and particularly the "vulnerable" plaque is emphasized. Yet, even with the eradication of coronary disease, the potential for very long life would not be likely. Only with the identification and eradication of the causative factors of aging can this possibility have a chance of becoming reality.

Monocyte and macrophage heterogeneity

Heterogeneity of the macrophage lineage has long been recognized and, in part, is a result of the specialization of tissue macrophages in particular microenvironments. Circulating monocytes give rise to mature macrophages and are also heterogeneous themselves, although the physiological relevance of this is not completely understood. However, as we discuss here, recent studies have shown that monocyte heterogeneity is conserved in humans and mice, allowing dissection of its functional relevance: the different monocyte subsets seem to reflect developmental stages with distinct physiological roles, such as recruitment to inflammatory lesions or entry to normal tissues. These advances in our understanding have implications for the development of therapeutic strategies that are targeted to modify particular subpopulations of monocytes.

Development and validation of novel imaging technologies to assist translational studies in atherosclerosis

In the past decade, significant progress has been made to visualize atherosclerotic disease. Until recently, imaging technologies mainly focused on lumen and vessel wall visualization. Current advances and knowledge on the molecular mechanisms of initiation and progression of atherosclerosis has emphasized the need for imaging technologies and probes that can image function and biology rather than anatomy. This field of molecular imaging is now in rapid development with new imaging agents that aim at visualizing processes involved in atherosclerosis such as inflammation, macrophage activation, protease activity, angiogenesis, apoptosis, lipid accumulation and thrombus formation.:

Diagnostic and clinical perspectives of fusion imaging in cardiology: is the total greater than the sum of its parts?

Positron emission tomography, cardiovascular magnetic resonance and multislice computed tomography have contributed to changing our pathophysiological understanding of many conditions. Clinically, they have provided new tools for the identification of preclinical disease and a better understanding of how disease progresses. The application of these imaging modalities to preclinical disease and the use of these techniques in patients with overt cardiovascular disease are reviewed.

18F-choline images murine atherosclerotic plaques ex vivo

OBJECTIVE

Current imaging modalities of atherosclerosis mainly visualize plaque morphology. Valuable insight into plaque biology was achieved by visualizing enhanced metabolism in plaque-derived macrophages using 18F-fluorodeoxyglucose (18F-FDG). Similarly, enhanced uptake of 18F-fluorocholine (18F-FCH) was associated with macrophages surrounding an abscess. As macrophages are important determinants of plaque vulnerability, we tested 18F-FCH for plaque imaging.

METHODS AND RESULTS

We injected 18F-FCH (n=5) or 18F-FDG (n=5) intravenously into atherosclerotic apolipoprotein E-deficient mice. En face measurements of aortae isolated 20 minutes after 18F-FCH injections demonstrated an excellent correlation between fat stainings and autoradiographies (r=0.842, P<0.0001), achieving a sensitivity of 84% to detect plaques by 18F-FCH. In contrast, radiotracer uptake 20 minutes after 18F-FDG injections correlated less with en face fat stainings (r=0.261, P<0.05), reaching a sensitivity of 64%. Histological analyses of cross-sections 20 minutes after coinjections of 18F-FCH and 14C-FDG (n=3) showed that 18F-FCH uptake correlated better with fat staining (r=0.740, P<0.0001) and macrophage-positive areas (r=0.740, P<0.0001) than 14C-FDG (fat: r=0.236, P=0.29 and CD68 staining: r=0.352, P=0.11), respectively.

CONCLUSIONS

18F-FCH identifies murine plaques better than 18F-FDG using ex vivo imaging. Enhanced 18F-FCH uptake into macrophages may render this tracer a promising candidate for imaging plaques in patients.