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Alam L, Omar AMS, Patel KK. Improved Performance of PET Myocardial Perfusion Imaging Compared to SPECT in the Evaluation of Suspected CAD. Curr Cardiol Rep 2023; 25:281-293. [PMID: 36826689 DOI: 10.1007/s11886-023-01851-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE OF REVIEW Myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) has played a central role in the non-invasive evaluation of patients with obstructive coronary artery disease (CAD) for decades. In this review, we discuss the key differences and advantages of positron emission tomography (PET) MPI over SPECT MPI as it relates to the diagnosis, prognosis, as well as clinical decision-making in patients with suspected CAD. RECENT FINDINGS Stress-induced perfusion abnormalities on SPECT help estimate presence, extent, and location of ischemia and flow-limiting obstructive CAD, help with risk stratification, and serve as a gatekeeper to identify patients who will benefit from downstream revascularization versus medical management. Some of the major limitations of SPECT include soft-tissue attenuation artifacts, underestimation of ischemia due to reliance on relative perfusion assessment, and longer protocols with higher radiation dose when performed with traditional equipment. PET MPI addresses most of these limitations and offers better quality images, higher diagnostic accuracy along with shorter protocols and lower radiation dose to the patient. A special advantage of PET scanning lies in the ability to quantify absolute myocardial blood flow and assess true extent of epicardial involvement along with identifying non-obstructive phenotypes of CAD such as diffuse atherosclerosis and microvascular dysfunction. In addition, stress acquisition at/near peak stress with PET allows us to measure left ventricular ejection fraction reserve and myocardial blood flow reserve, which help with identifying patients at a higher risk of future cardiac events and optimally select candidates for revascularization. The several technical advantages of PET MPI position as a superior method to diagnose obstructive and non-obstructive phenotypes of ischemic heart disease affecting the entirety of the coronary circulation offer incremental value for risk stratification and guide post-test management strategy for patients with suspected CAD.
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Affiliation(s)
- Loba Alam
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alaa Mabrouk Salem Omar
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Krishna K Patel
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA.
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Schindler TH, Fearon WF, Pelletier-Galarneau M, Ambrosio G, Sechtem U, Ruddy TD, Patel KK, Bhatt DL, Bateman TM, Gewirtz H, Shirani J, Knuuti J, Gropler RJ, Chareonthaitawee P, Slart RHJA, Windecker S, Kaufmann PA, Abraham MR, Taqueti VR, Ford TJ, Camici PG, Schelbert HR, Dilsizian V. PET for Detection and Reporting Coronary Microvascular Dysfunction: A JACC: Cardiovascular Imaging Expert Panel Statement. JACC Cardiovasc Imaging 2023; 16:536-548. [PMID: 36881418 DOI: 10.1016/j.jcmg.2022.12.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/14/2022] [Accepted: 12/02/2022] [Indexed: 02/11/2023]
Abstract
Angina pectoris and dyspnea in patients with normal or nonobstructive coronary vessels remains a diagnostic challenge. Invasive coronary angiography may identify up to 60% of patients with nonobstructive coronary artery disease (CAD), of whom nearly two-thirds may, in fact, have coronary microvascular dysfunction (CMD) that may account for their symptoms. Positron emission tomography (PET) determined absolute quantitative myocardial blood flow (MBF) at rest and during hyperemic vasodilation with subsequent derivation of myocardial flow reserve (MFR) affords the noninvasive detection and delineation of CMD. Individualized or intensified medical therapies with nitrates, calcium-channel blockers, statins, angiotensin-converting enzyme inhibitors, angiotensin II type 1-receptor blockers, beta-blockers, ivabradine, or ranolazine may improve symptoms, quality of life, and outcome in these patients. Standardized diagnosis and reporting criteria for ischemic symptoms caused by CMD are critical for optimized and individualized treatment decisions in such patients. In this respect, it was proposed by the cardiovascular council leadership of the Society of Nuclear Medicine and Molecular Imaging to convene thoughtful leaders from around the world to serve as an independent expert panel to develop standardized diagnosis, nomenclature and nosology, and cardiac PET reporting criteria for CMD. This consensus document aims to provide an overview of the pathophysiology and clinical evidence of CMD, its invasive and noninvasive assessment, standardization of PET-determined MBFs and MFR into "classical" (predominantly related to hyperemic MBFs) and "endogen" (predominantly related to resting MBF) normal coronary microvascular function or CMD that may be critical for diagnosis of microvascular angina, subsequent patient care, and outcome of clinical CMD trials.
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Affiliation(s)
- Thomas H Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine-Cardiovascular, Washington University in St Louis School of Medicine, St Louis, Missouri, USA.
| | - William F Fearon
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
| | | | - Giuseppe Ambrosio
- University of Perugia School of Medicine Ospedale S. Maria della Misericordia Perugia, Italy
| | - Udo Sechtem
- Cardiologicum Stuttgart, Stuttgart, Baden-Wuerttemberg, Germany
| | | | - Krishna K Patel
- Icahn School of Medicine at Mount Sinai, Zena, New York, New York, USA; Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Timothy M Bateman
- Saint-Lukes Health System and the Mid-America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Henry Gewirtz
- Cardiac Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jamshid Shirani
- Cardiology, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Juhani Knuuti
- Heart Center, Turku University Hospital, Turku, Finland
| | - Robert J Gropler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine-Cardiovascular, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | | | - Riemer H J A Slart
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Maria R Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, University of California, San Francisco, California, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Thomas J Ford
- The University of Newcastle, Faculty of Medicine, Newcastle, Australia
| | - Paolo G Camici
- San Raffaele Hospital, Milan Italy; Vita Salute University, Milan, Italy
| | - Heinrich R Schelbert
- Department of Molecular Imaging and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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