Longitudinal 18F-FDG PET imaging in a rat model of autoimmune myocarditis

Comparing the Diagnostic Value of FDG PET or PET/CT With FDG PET/MR in Inflammatory Bowel Disease-A Systematic Review and Meta-analysis

BACKGROUND

The aim of this study was to compare the diagnostic value of 18 F-FDG PET or PET/CT with FDG PET/MR in patients with inflammatory bowel disease (IBD).

METHODS

A comprehensive search was performed in PubMed for studies reporting the diagnostic performance of FDG PET (PET/CT) and FDG PET/MR in IBD from the inception of the database to March 14, 2024, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Fourteen studies were included in this systematic review and meta-analysis. Pooled estimates of segment-based sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for FDG PET (PET/CT) and FDG PET/MR were calculated alongside 95% confidence intervals. Summary receiver operating characteristic (SROC) curves were plotted, and the area under the SROC curve was determined alongside the Q * index.

RESULTS

The segment-based pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the SROC curve of FDG PET (PET/CT) for diagnosing IBD (9 studies) were 0.81, 0.86, 5.76, 0.22, 31.92, and 0.92, respectively. Those of FDG PET/MR (5 studies) were 0.78, 0.92, 10.97, 0.25, 51.79, and 0.95. There was no significant difference in the abilities of detecting or excluding IBD between FDG PET (PET/CT) and FDG PET/MR.

CONCLUSIONS

For diagnostic value in patients with IBD, there was no significant difference between FDG PET (PET/CT) and FDG PET/MR. Both FDG PET (PET/CT) and FDG PET/MR have demonstrated high diagnostic performance for accurate diagnosing in patients with IBD.

Cardiovascular complications of rheumatoid arthritis

PURPOSE OF REVIEW

Rheumatoid arthritis (RA) patients remain at higher cardiovascular (CV) risk compared to non-RA patients, driven by accelerated atherosclerosis, leading to plaque rupture and acute CV events (CVE), including heart failure (HF). It has been hypothesized that chronic inflammation is the main driving force behind such outcomes. We summarize the current evidence supporting this hypothesis, focusing on arterial disease and myocardial disease.

RECENT FINDINGS

RA patients demonstrate higher prevalence of subclinical atherosclerosis (high risk plaque and arterial inflammation) compared to non-RA patients, with RA disease activity correlating independently with CVE and death. Nonischemic HF with preserved ejection fraction (HFpEF) is more common in RA compared to non-RA, with subclinical myocardial structural and functional alterations also more prevalent in RA. HFpEF and myocardial remodeling and dysfunction bear a strong and independent association with inflammatory correlates.

SUMMARY

All of this suggests that inflammation contributes to enhanced risk of CVE in RA. A more accurate and specific CV risk stratification tool for RA, incorporating biomarkers or imaging, is needed. Likewise, more prospective studies outlining the trajectory from preclinical to clinical HF, incorporating biomarkers and imaging, are also needed.

Preclinical Imaging of Cardiovascular Disesase

Noninvasive imaging techniques, such as SPECT, PET, CT, echocardiography, or MRI, have become essential in cardiovascular research. They allow for the evaluation of biological processes in vivo without the need for invasive procedures. Nuclear imaging methods, such as SPECT and PET, offer numerous advantages, including high sensitivity, reliable quantification, and the potential for serial imaging. Modern SPECT and PET imaging systems, equipped with CT and MRI components in order to get access to morphological information with high spatial resolution, are capable of imaging a wide range of established and innovative agents in both preclinical and clinical settings. This review highlights the utility of SPECT and PET imaging as powerful tools for translational research in cardiology. By incorporating these techniques into a well-defined workflow- similar to those used in clinical imaging- the concept of "bench to bedside" can be effectively implemented.

The assessment of left ventricular volume and function in gated small animal 18F-FDG PET/CT imaging: a comparative study of three commercially available software tools

BACKGROUND

Several software tools have been developed for gated PET imaging that use distinct algorithms to analyze tracer uptake, myocardial perfusion, and left ventricle volumes and function. Studies suggest that different software tools cannot be used interchangeably in humans. In this study, we sought to compare the left ventricular parameters in gated 18F-FDG PET/CT imaging in mice by three commercially available software tools: PMOD, MIM, and QGS.

METHODS AND RESULTS

Healthy mice underwent ECG-gated 18F-FDG imaging using a small-animal nanoPET/CT (Mediso) under isoflurane narcosis. Reconstructed gates PET images were subsequently analyzed in three different software tools, and cardiac volume and function (end-diastolic (EDV), end-systolic volumes (ESV), stroke volume (SV), and ejection fraction (EF)) were evaluated. While cardiac volumes correlated well between PMOD, MIM, and QGS, the left ventricular parameters and cardiac function differed in agreement using Bland-Altman analysis. EDV in PMOD vs. QGS: r = 0.85; p < 0.001, MIM vs. QGS: r = 0.92; p < 0.001, and MIM vs. PMOD: r = 0.88; p < 0.001, showed good correlations. Correlation was also found in ESV: PMOD vs. QGS: r = 0.48; p = 0.07, MIM vs QGS: r = 0.79; p < 0.001, and MIM vs. PMOD: r = 0.69; p < 0.01. SV showed good correlations in: PMOD vs. QGS: r = 0.73; p < 0.01, MIM vs. QGS: r = 0.86; p < 0.001, and MIM vs. PMOD: r = 0.92; p < 0.001. However, EF among correlated poorly: PMOD vs. QGS: r = -0.31; p = 0.26, MIM vs. QGS: r = 0.48; p = 0.07, and MIM vs. PMOD: r = 0.23; p = 0.41. Inter-class and intra-class correlation coefficient were > 0.9 underlining repeatability in using PMOD, MIM, and QGS for cardiac volume and function assessment.

CONCLUSIONS

All three commercially available software tools are feasible in small animal cardiac volume assessment in gated 18F-FDG PET/CT imaging. However, due to software-related differences in agreement analysis for cardiac volumes and function, PMOD, MIM, and QGS cannot be used interchangeably in murine research.

Recent Advances in Cardiovascular Diseases Research Using Animal Models and PET Radioisotope Tracers

Cardiovascular diseases (CVD) is a collective term describing a range of conditions that affect the heart and blood vessels. Due to the varied nature of the disorders, distinguishing between their causes and monitoring their progress is crucial for finding an effective treatment. Molecular imaging enables non-invasive visualisation and quantification of biological pathways, even at the molecular and subcellular levels, what is essential for understanding the causes and development of CVD. Positron emission tomography imaging is so far recognized as the best method for in vivo studies of the CVD related phenomena. The imaging is based on the use of radioisotope-labelled markers, which have been successfully used in both pre-clinical research and clinical studies. Current research on CVD with the use of such radioconjugates constantly increases our knowledge and understanding of the causes, and brings us closer to effective monitoring and treatment. This review outlines recent advances in the use of the so-far available radioisotope markers in the research on cardiovascular diseases in rodent models, points out the problems and provides a perspective for future applications of PET imaging in CVD studies.

Impact of shear wave dispersion slope analysis for assessing the severity of myocarditis

This study aimed to elucidate the utility of a novel ultrasound-based technique, shear wave dispersion slope (SWDS) analysis, which estimates tissue viscosity, for evaluating the severity of myocardial inflammation. Experimental autoimmune myocarditis (EAM) at different disease phases [3-week (acute phase): n = 10, 5-week (subacute phase): n = 9, and 7-week (late phase): n = 11] were developed in male Lewis rats. SWDS was measured in the right and the left ventricular free walls (RVFW and LVFW) under a retrograde perfusion condition. Histological myocardial inflammation was evaluated by CD68 staining. The accumulation of CD68-positive cells was severe in the myocardium of the EAM 3-week group. The median (interquartile range) SWDS of RVFW was significantly higher in the EAM 3-week group [9.9 (6.5-11.0) m/s/kHz] than in the control group [5.4 (4.5-6.8) m/s/kHz] (P = 0.034). The median SWDS of LVFW was also significantly higher in the EAM 3-week group [8.1 (6.4-11.0) m/s/kHz] than in the control group [4.4 (4.2-4.8) m/s/kHz] (P = 0.003). SWDS and the percentage of CD68-positive area showed a significant correlation in RVFW (R2 = 0.64, P < 0.001) and LVFW (R2 = 0.73, P < 0.001). This study showed that SWDS was elevated in ventricular walls with acute inflammation and also significantly correlated with the degree of myocardial inflammation. These results suggest the potential of SWDS in estimating the histological severity of acute myocarditis.

Myocardial Dysfunction and Heart Failure in Rheumatoid Arthritis

Rheumatoid arthritis (RA) patients have almost twice the risk of heart failure (HF) as individuals without RA, even with adjustment for the presence of ischemic heart disease. Moreover, RA patients remain at a 2-fold higher risk of mortality from HF compared to non-RA patients. These observations suggest that RA-specific inflammatory pathways are significant contributors to this increased risk of HF. Herein we summarize the epidemiology of HF in RA patients, the differences in myocardial structure or function between RA patients and non-RA patients without clinical signs of HF, and data on the role of systemic and local inflammation in RA HF pathophysiology. We also discuss the impact of subduing inflammation through the use of RA disease-modifying therapies on HF and myocardial structure and function, emphasizing gaps in the literature and areas needing further research.

Uptake of nicotinic acetylcholine receptor imaging agent is reduced in the pro-inflammatory macrophage

INTRODUCTION

Macrophages play a vital role in the development of atherosclerotic cardiovascular disease. Macrophages are functionally and phenotypically heterogeneous immune cells and commonly exist in two distinct or polarized subsets: pro-inflammatory M1 and anti-inflammatory M2 phenotypes. Previous reports suggest that stimulation of α7 or α4β2 nicotinic acetylcholine receptors (nAChRs) in macrophages leads to an anti-inflammatory response. However, the biological link between nAChR expression on macrophages and the polarization state is unknown. Therefore, we evaluated the relationship between nAChRs and polarized macrophages in peritoneal macrophages and atherosclerotic plaques of apolipoprotein E knockout (ApoE-/-) mice.

METHODS

Peritoneal macrophages isolated from mice were polarized into M1 and M2 macrophages, and the uptake of the nAChR-imaging agents, (R)-2-[11C]methylamino-benzoic acid 1-aza-bicyclo[2.2.2]oct-3-yl ester ([11C]MeQAA) or 2-[18F]fluoro-3-(2(S)-azetidinylmethoxy) pyridine ([18F]2FA), and 2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) was assessed. We also evaluated the accumulation of imaging agents in atherosclerotic plaques of ApoE-/- mice by autoradiography. After an autoradiogram was obtained, the same aortic tissue was used for immunohistochemical staining of CD68, inducible nitric oxide synthase (iNOS), and arginine-1.

RESULTS

In an in vitro assay, the uptake of [11C]MeQAA or [18F]2FA was lower in M1 than in M0 and M2 macrophages. In comparison, the uptake of [18F]FDG was higher in M1 macrophages. Ex vivo autoradiography showed that [11C]MeQAA was localized to the extensive plaque area. By contrast, the accumulation of [18F]2FA and [18F]FDG was heterogeneous and found only in some plaques. Moreover, the expression of CD68 and iNOS was higher in [18F]2FA non-uptake than [18F]2FA uptake plaques.

CONCLUSION

Macrophage polarization was related to nAChR expression, and α4β2 nAChR expression was suppressed in the M1 macrophage. These findings suggest that nAChR imaging has the potential to identify the inflammatory status of atherosclerotic plaque.

Molecular imaging of inflammation crosstalk along the cardio-renal axis following acute myocardial infarction

Rationale: Acute myocardial infarction (MI) triggers a systemic inflammatory response including crosstalk along the heart-kidney axis. We employed radionuclide-based inflammation-targeted whole-body molecular imaging to identify potential cardio-renal crosstalk after MI in a translational setup. Methods: Serial whole-body positron emission tomography (PET) with the specific CXCR4 ligand 68Ga-Pentixafor was performed after MI in mice. Tracer retention in kidneys and heart was compared to hematopoietic organs to evaluate systemic inflammation, validated by ex vivo analysis and correlated with progressive contractile dysfunction. Additionally, 96 patients underwent 68Ga-Pentixafor PET within the first week after MI, for systems-based image analysis and to determine prognostic value for adverse renal outcome. Results: In mice, transient myocardial CXCR4 upregulation occurred early after MI. Cardiac and renal PET signal directly correlated over the time course (r = 0.62, p < 0.0001), suggesting an inflammatory link between organs. Ex-vivo autoradiography (r = 0.9, p < 0.01) and CD68 immunostaining indicated signal localization to inflammatory cell content. Renal signal at 7d was inversely proportional to left ventricular ejection fraction at 6 weeks after MI (r = -0.79, p < 0.01). In patients, renal CXCR4 signal also correlated with signal from infarct (r = 0.25, p < 0.05) and remote myocardium (r = 0.39, p < 0.0001). Glomerular filtration rate (GFR) was available in 48/96 (50%) during follow-up. Worsening of renal function (GFR loss >5 mL/min/1.73m2), occurred a mean 80.5 days after MI in 16/48 (33.3%). Kaplan-Meier analysis revealed adverse renal outcome for patients with elevated remote myocardial CXCR4 signal (p < 0.05). Multivariate Cox analysis confirmed an independent predictive value (relative to baseline GFR, LVEF, infarct size; HR, 5.27). Conclusion: Systems-based CXCR4-targeted molecular imaging identifies inflammatory crosstalk along the cardio-renal axis early after MI.

Immuno-metabolic interfaces in cardiac disease and failure

The interplay between the cardiovascular system, metabolism, and inflammation plays a central role in the pathophysiology of a wide spectrum of cardiovascular diseases, including heart failure. Here, we provide an overview of the fundamental aspects of the interrelation between inflammation and metabolism, ranging from the role of metabolism in immune cell function to the processes how inflammation modulates systemic and cardiac metabolism. Furthermore, we discuss how disruption of this immuno-metabolic interface is involved in the development and progression of cardiovascular disease, with a special focus on heart failure. Finally, we present new technologies and therapeutic approaches that have recently emerged and hold promise for the future of cardiovascular medicine.

The year 2019 in the European Heart Journal - Cardiovascular Imaging: part II

The European Heart Journal - Cardiovascular Imaging was launched in 2012 and has during these years become one of the leading multimodality cardiovascular imaging journal. The journal is now established as one of the top cardiovascular journals and is the most important cardiovascular imaging journal in Europe. The most important studies published in our Journal from 2019 will be highlighted in two reports. Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease. While Part I of the review has focused on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging.

The year 2019 in the European Heart Journal-Cardiovascular Imaging: Part I

The European Heart Journal-Cardiovascular Imaging was launched in 2012 and has during these years become one of the leading multimodality cardiovascular imaging journals. The journal is now established as one of the top cardiovascular journals and is the most important cardiovascular imaging journal in Europe. The most important studies published in our Journal in 2019 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.

Emerging F-18-Labelled PET Myocardial Perfusion Tracers

PURPOSE OF REVIEW

PET myocardial perfusion imaging (MPI) is an established modality for the evaluation of ischemic heart disease and quantitation of myocardial blood flow (MBF). New F-18-labelled radiopharmaceuticals have been recently developed to overcome some of the limitations of currently used tracers such as the need of an on-site cyclotron. The characteristics of the new tracers and the clinical results obtained so far will be reviewed.

RECENT FINDINGS

Most of the interest in the field of ¹⁸F-labelled radiotracers for PET MPI has been concentrated on MC-1 inhibitors, the prototype of which is ¹⁸F-flurpiridaz. It was shown in experimental and clinical reports that these radiotracers allow good quality rest/stress MPI studies and a reliable quantitation of MBF. Recent evidence suggests that PET MPI with ¹⁸F-flurpiridaz may provide a superior diagnostic accuracy for obstructive CAD even if a large comparative clinical trial with SPECT is still ongoing.

Molecular magnetic resonance imaging of activated platelets allows noninvasive detection of early myocarditis in mice

MRI sensitivity for diagnosis and localization of early myocarditis is limited, although it is of central clinical interest. The aim of this project was to test a contrast agent targeting activated platelets consisting of microparticles of iron oxide (MPIO) conjugated to a single-chain antibody directed against ligand-induced binding sites (LIBS) of activated glycoprotein IIb/IIIa (= LIBS-MPIO). Myocarditis was induced by subcutaneous injection of an emulsion of porcine cardiac myosin and complete Freund’s adjuvant in mice. 3D 7 T in-vivo MRI showed focal signal effects in LIBS-MPIO injected mice 2 days after induction of myocarditis, whereas in control-MPIO injected mice no signal was detectable. Histology confirmed CD41-positive staining, indicating platelet involvement in myocarditis in mice as well as in human specimens with significantly higher LIBS-MPIO binding compared to control-MPIO in both species. Quantification of the myocardial MRI signal confirmed a signal decrease after LIBS-MPIO injection and significant less signal in comparison to control-MPIO injection. These data show, that platelets are involved in inflammation during the course of myocarditis in mice and humans. They can be imaged non-invasively with LIBS-MPIO by molecular MRI at an early time point of the inflammation in mice, which is a valuable approach for preclinical models and of interest for both diagnostic and prognostic purposes.

Nuclear cardiology in the context of multimodality imaging to detect cardiac toxicity from cancer therapeutics: Established and emerging methods

The complexity of cancer therapies has vastly expanded in the last decade, along with type and severity of cardiac toxicities associated with these treatments. Prevention of pre-clinical cardiotoxicity may improve cardiovascular outcomes and circumvent the decision to place life-sustaining chemotherapeutic agents on hold, making the early detection of cancer therapeutic related cardiac toxicity with non-invasive imaging essential to the care of these patients. There are several established methods of cardiac imaging in the areas of nuclear cardiology, echocardiography, computed tomography, and cardiac magnetic resonance imaging that are used to assess for cardiovascular toxicity of cancer treatments, with several methods under development. The following review will provide an overview of current and emerging imaging techniques in these areas.

Folate Receptor β-Targeted PET Imaging of Macrophages in Autoimmune Myocarditis

Currently available imaging techniques have limited specificity for the detection of active myocardial inflammation. Aluminum ¹⁸F-labeled 1,4,7-triazacyclononane-N,N',N″-triacetic acid conjugated folate (¹⁸F-FOL) is a PET tracer targeting folate receptor β (FR-β), which is expressed on activated macrophages at sites of inflammation. We evaluated ¹⁸F-FOL PET for the detection of myocardial inflammation in rats with autoimmune myocarditis and studied the expression of FR-β in human cardiac sarcoidosis specimens. Methods: Myocarditis was induced by immunizing rats (n = 18) with porcine cardiac myosin in complete Freund adjuvant. Control rats (n = 6) were injected with Freund adjuvant alone. ¹⁸F-FOL was intravenously injected, followed by imaging with a small-animal PET/CT scanner and autoradiography. Contrast-enhanced high-resolution CT or ¹⁸F-FDG PET images were used for coregistration. Rat tissue sections and myocardial autopsy samples from 6 patients with cardiac sarcoidosis were studied for macrophages and FR-β. Results: The myocardium of 10 of 18 immunized rats showed focal macrophage-rich inflammatory lesions, with FR-β expression occurring mainly in M1-polarized macrophages. PET images showed focal myocardial ¹⁸F-FOL uptake colocalizing with inflammatory lesions (SUV_mean, 2.1 ± 1.1), whereas uptake in the remote myocardium of immunized rats and controls was low (SUV_mean, 0.4 ± 0.2 and 0.4 ± 0.1, respectively; P < 0.01). Ex vivo autoradiography of tissue sections confirmed uptake of ¹⁸F-FOL in myocardial inflammatory lesions. Uptake of ¹⁸F-FOL in inflamed myocardium was efficiently blocked by a nonlabeled FR-β ligand folate glucosamine in vivo. The myocardium of patients with cardiac sarcoidosis showed many FR-β-positive macrophages in inflammatory lesions. Conclusion: In a rat model of autoimmune myocarditis, ¹⁸F-FOL shows specific uptake in inflamed myocardium containing macrophages expressing FR-β, which were also present in human cardiac sarcoid lesions. Imaging of FR-β expression is a potential approach for the detection of active myocardial inflammation.

Non-invasive contrast enhanced ultrasound molecular imaging of inflammation in autoimmune myocarditis for prediction of left ventricular fibrosis and remodeling

Background

Myocarditis can lead to myocyte loss and myocardial fibrosis resulting in dilated cardiomyopathy (DCMP). Currently employed methods for assessing the risk for development of DCMP are inaccurate or rely on invasive myocardial biopsies. We hypothesized that molecular imaging of tissue inflammation with contrast enhanced ultrasound during peak inflammation in myocarditis could predict development of fibrosis and impaired left ventricular function.

Methods and results

Experimental autoimmune myocarditis (EAM) was induced in Balbc mice by injection of the α-myosin heavy chain peptide. Contrast enhanced ultrasound (CEU) using microbubbles targeted to leukocytes (MB_Lc), to CD4+ lymphocytes (MB_CD4), and to the endothelial cell adhesion molecule P-selectin (MB_PSel) was performed during the expected EAM peak inflammatory activity 21 days after induction. High resolution ultrasound, invasive hemodynamic measurements and fibrosis quantification were done 63 days after EAM assessment. All tested microbubbles correlated to fibrosis (MB_Lc spearman r 0.28, p 0.047, MB_CD4 r 0.44, p 0.01, MB_PSel r 0.73, p 0.02), however, correlations were weak overall and the spread of data was considerable. Also, targeted CEU data on day 21 did not correlate to hemodynamic and functional data on day 63.

Conclusions

Ultrasound molecular imaging using targeted microbubbles during the peak inflammatory activity of myocarditis correlates weakly with later development of fibrosis but not with hemodynamic or left ventricular functional parameters.

Imaging of myocarditis and inflammatory cardiomyopathies

Myocarditis encompasses a wide range of myocardial inflammatory diseases, including acute myocarditis, chronic myocarditis and inflammatory cardiomyopathies, and myocardial inflammation associated with other cardiomyopathies. Because of this heterogeneity in clinical presentation, and the infrequent use of endomyocardial biopsy, cardiac imaging has gradually acquired a key role in the non-invasive detection of myocardial inflammation, the assessment of aetiology and the management of specific therapies. This article summarizes the issue of myocarditis and myocardial inflammation in clinical practice, and reviews the role of different non-invasive imaging techniques in the exploration of myocardial inflammation.

Early Detection of Localized Immunity in Experimental Autoimmune Myocarditis Using [99mTc]Fucoidan SPECT

PURPOSE

The aim of the study was to evaluate the ability of technetium-99m-fucoidan ([^99mTc]fucoidan), a molecular imaging agent specific for selectins, in the assessment of early localized immunity in a rat model of experimental autoimmune myocarditis (EAM).

PROCEDURES

EAM was induced in Lewis rats and troponin T; brain natriuretic peptide (BNP) and anti-myosin antibodies were measured in plasma. Separately, [^99mTc]fucoidan single-photon emission computed tomography (SPECT)/x-ray computed tomography (CT) was performed in the very early phase of myocarditis at 10, 15, and 21 days after immunization. Then, hearts were collected and used for autoradiography, well counting, histology, and flow cytometry analysis.

RESULTS

The EAM acute phase is characterized by extensive myocardial necrosis, release of troponin and BNP, and pericardial effusion. [^99mTc]Fucoidan uptake was significantly increased in EAM compared with controls starting from D15. There was a close relationship between uptake of the tracer and myocardial content in CD45+, CD8+, CD11b+, and CD31+ cells.

CONCLUSIONS

[^99mTc]Fucoidan SPECT/CT accurately diagnosed the autoimmune attack in the early steps of EAM and could be used to monitor disease evolution and therapy efficiency.

Dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is a clinical diagnosis characterized by left ventricular or biventricular dilation and impaired contraction that is not explained by abnormal loading conditions (for example, hypertension and valvular heart disease) or coronary artery disease. Mutations in several genes can cause DCM, including genes encoding structural components of the sarcomere and desmosome. Nongenetic forms of DCM can result from different aetiologies, including inflammation of the myocardium due to an infection (mostly viral); exposure to drugs, toxins or allergens; and systemic endocrine or autoimmune diseases. The heterogeneous aetiology and clinical presentation of DCM make a correct and timely diagnosis challenging. Echocardiography and other imaging techniques are required to assess ventricular dysfunction and adverse myocardial remodelling, and immunological and histological analyses of an endomyocardial biopsy sample are indicated when inflammation or infection is suspected. As DCM eventually leads to impaired contractility, standard approaches to prevent or treat heart failure are the first-line treatment for patients with DCM. Cardiac resynchronization therapy and implantable cardioverter-defibrillators may be required to prevent life-threatening arrhythmias. In addition, identifying the probable cause of DCM helps tailor specific therapies to improve prognosis. An improved aetiology-driven personalized approach to clinical care will benefit patients with DCM, as will new diagnostic tools, such as serum biomarkers, that enable early diagnosis and treatment.

Moving into the next era of PET myocardial perfusion imaging: introduction of novel 18F-labeled tracers

The heart failure epidemic continues to rise with coronary artery disease as one of its main causes. Novel concepts for risk stratification to guide the referring cardiologist towards revascularization procedures are of significant value. Myocardial perfusion imaging using single-photon emission computed tomography (SPECT) agents has demonstrated high accuracy for the detection of clinically relevant stenoses. With positron emission tomography (PET) becoming more widely available, mainly due to its diagnostic performance in oncology, perfusion imaging with that modality is more practical than in the past and overcomes existing limitations of SPECT MPI. Advantages of PET include more reliable quantification of absolute myocardial blood flow, the routine use of computed tomography for attenuation correction, a higher spatiotemporal resolution and a higher count sensitivity. Current PET radiotracers such as rubidium-82 (half-life, 76 s), oxygen-15 water (2 min) or nitrogen-13 ammonia (10 min) are labeled with radionuclides with very short half-lives, necessitating that stress imaging is performed under pharmacological vasodilator stress instead of exercise testing. However, with the introduction of novel ¹⁸F-labeled MPI PET radiotracers (half-life, 110 min), the intrinsic advantages of PET can be combined with exercise testing. Additional advantages of those radiotracers include, but are not limited to: potentially improved cost-effectiveness due to the use of pre-existing delivery systems and superior imaging qualities, mainly due to the shortest positron range among available PET MPI probes. In the present review, widely used PET MPI radiotracers will be reviewed and potential novel ¹⁸F-labeled perfusion radiotracers will be discussed.