BACKGROUND: While Rubidium-82 (Rb) positron emission tomography (PET) myocardial perfusion imaging (MPI) has a well-established myocardial flow reserve (MFR) cut-off of <2 for prognosis, no consensus exists for [O]HO PET...BACKGROUND: While Rubidium-82 (Rb) positron emission tomography (PET) myocardial perfusion imaging (MPI) has a well-established myocardial flow reserve (MFR) cut-off of <2 for prognosis, no consensus exists for [O]HO PET. METHODS: Forty-four patients referred for routine Rb PET MPI underwent same-day [O]HO PET MPI. Myocardial blood flow (MBF) and MFR measurements corrected for nonlinear Rb extraction were compared. Additionally, a pooled analysis including five similar studies was conducted. RESULTS: Global MBF was higher at rest (relative difference 26%, 95% confidence interval [CI]: 21-31) and lower at stress (relative difference -17%, 95% CI: -24 to -10) measured by Rb vs [O]HO PET. Global MFR was lower measured by Rb vs [O]HO PET (relative difference -42%, 95% CI: -48% to -37%). The directions of the observed biases were confirmed in the pooled analysis. Correction for nonlinear Rb extraction with the equation by Prior et al. compared to Lortie et al. demonstrated better agreement of stress MBF between the tracers. Applying the relative differences of MFR, the prognostic cut-off for MFR of 2 using Rb PET corresponds to an MFR using [O]HO PET of 3.1 (95% CI: 2.9-3.3) in the present study and 2.5 (95% CI: 2.4-2.6) in the pooled analysis. CONCLUSIONS: Rb PET overestimates global MBF at rest, underestimates global MBF at stress, and underestimates global MFR compared with [O]HO PET, despite correction for nonlinear extraction. Validation of prognostic cut-off values for [O]HO PET is needed, and caution should be taken in directly comparing MBF and MFR obtained by these two tracers.
Barrett O, Shanbhag A, Zaid R
… +9 more, Miller RJH, Lemley M, Builoff V, Liang JX, Kavanagh PB, Buckley C, Dey D, Berman DS, Slomka PJ
J Nucl Cardiol
· 2025 Dec · PMID 41101453
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BACKGROUND: Positron emission tomography (PET) myocardial perfusion imaging (MPI) is a powerful tool for predicting coronary artery disease (CAD). Coronary artery calcium (CAC) provides incremental risk stratification to...BACKGROUND: Positron emission tomography (PET) myocardial perfusion imaging (MPI) is a powerful tool for predicting coronary artery disease (CAD). Coronary artery calcium (CAC) provides incremental risk stratification to PET-MPI and enhances diagnostic accuracy. We assessed the additive value of the CAC score, derived from PET/CT attenuation maps to stress total perfusion deficit (TPD) results using the novel F-flurpiridaz tracer in detecting significant CAD. METHODS: Patients from the F-flurpiridaz phase III clinical trial who underwent PET/CT MPI with the F-flurpiridaz tracer, had available computed tomography attenuation correction (CTAC) scans for CAC scoring, and underwent invasive coronary angiography (ICA) within a 6-month period between 2011 and 2013 were included. TPD was quantified automatically, and CAC scores from CTAC scans were assessed using artificial intelligence (AI)-derived segmentation and manual scoring. Obstructive CAD was defined as ≥50% stenosis in the left main (LM) artery, or 70% or more stenosis in any of the other major epicardial vessels. Prediction performance for CAD was assessed by comparing the area under receiver operating characteristic curve (AUC) for stress TPD alone and in combination with the CAC score. RESULTS: Among 498 patients (72% males, median age 63 years) 30.1% had CAD. Incorporating the CAC score resulted in a greater AUC with manual scoring (AUC = .87, 95% confidence interval [CI]: .34-.90; P = .015) and AI-based scoring (AUC = .88, 95% CI: .85-.90; P = .002) compared to stress TPD alone (AUC = .84, 95% CI: .80-.92). CONCLUSIONS: Combining automatically derived TPD and CAC score enhances F-flurpiridaz PET MPI accuracy in detecting significant CAD, offering a method that can be routinely used with PET/CT scanners without additional scanning or technologist time.
Quantification of myocardial blood flow (MBF) and myocardial flow reserve (MFR) using SPECT myocardial perfusion imaging (MPI) represents a significant advancement in the field of nuclear cardiology. The introduction of...Quantification of myocardial blood flow (MBF) and myocardial flow reserve (MFR) using SPECT myocardial perfusion imaging (MPI) represents a significant advancement in the field of nuclear cardiology. The introduction of cadmium-zinc-telluride (CZT) solid-state detectors and innovative reconstruction algorithms has enabled dynamic SPECT imaging for MBF quantification. This review provides a guide to performing and interpreting quantitative SPECT MBF measurements in clinical practice. We discuss appropriate patient selection, protocol optimization, technical requirements, and acquisition parameters. Step-by-step approaches to image reconstruction, processing methods, and quantitative analysis are outlined, with emphasis on real-world clinical cases discussion. The review also addresses common technical challenges, potential pitfalls, and practical solutions for implementing this technology in routine clinical care. This article aims to facilitate wider adoption of SPECT MBF quantification as a valuable tool for diagnosing coronary artery disease and assessing coronary microvascular function.
The Society of Nuclear Medicine and Molecular Imaging (SNMMI), founded in 1954 and headquartered in Reston, Virginia, USA, is a nonprofit scientific and professional organization that promotes the science, technology, an...The Society of Nuclear Medicine and Molecular Imaging (SNMMI), founded in 1954 and headquartered in Reston, Virginia, USA, is a nonprofit scientific and professional organization that promotes the science, technology, and practical application of nuclear medicine and molecular imaging. SNMMI strives to be a leader in unifying, advancing, and optimizing molecular imaging with the ultimate goal of improving human health. With 13,000 members worldwide, SNMMI represents nuclear and molecular imaging professionals, all of whom are committed to the advancement of the field. The European Association of Nuclear Medicine (EANM) is a professional, nonprofit medical association that facilitates communication worldwide between individuals pursuing clinical and research excellence in nuclear medicine. The EANM was founded in 1985. The American College of Nuclear Medicine (ACNM) is a professional organization providing education, training, and advocacy for the most sought-after and trusted experts in nuclear medicine who deliver state-of-the-art and innovative care and service to patients and referring physicians. The ACNM's mission is to foster the highest standards in nuclear medicine consultation and service to referring physicians, hospitals, and the public, and to advance the science of nuclear medicine through a program of continuing professional development emphasizing high standards of nuclear medicine practice. The American Society of Nuclear Cardiology (ASNC) is the international home for nuclear cardiology and the largest professional society devoted exclusively to the field. ASNC membership includes more than 5700 nuclear cardiology professionals from around the world. Founded in 1993, ASNC's mission is to improve cardiovascular outcomes through image-guided patient management. ASNC's official publication is the Journal of Nuclear Cardiology. The SNMMI/EANM/ACNM will periodically define new standards/guidelines for nuclear medicine practice to help advance the science of nuclear medicine and to improve the quality of service to patients. Existing standards/guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each standard/guideline, representing a policy statement by the SNMMI/EANM/ACNM, has undergone a thorough consensus process in which it has been subjected to extensive review. The SNMMI, EANM, and ACNM recognize that the safe and effective use of diagnostic nuclear medicine imaging and therapy requires specific training, skills, and techniques, as described in each document. This document was jointly developed with ASNC. ASNC endorses this guideline, and it will be published alongside the Journal of Nuclear Medicine in the Journal of Nuclear Cardiology. The SNMMI, EANM, ASNC, and ACNM have written and approved these standards/guidelines to promote the use of high-quality nuclear medicine procedures. These standards/guidelines are intended to assist practitioners in providing appropriate care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the SNMMI, EANM, ASNC, andACNM caution against the use of these standards/guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by medical professionals considering the unique circumstances of each case. Thus, there is no implication that an approach differing from the standards/guidelines, standing alone, is below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the standards/guidelines when, in the reasonable judgment of the practitioner, such a course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the standards/guidelines. The practice of medicine involves not only the science but also the art of dealing with the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to these standards/guidelines will not ensure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these standards/guidelines is to assist practitioners in achieving this objective. Qualitycontrol andimprovement,safety,infectioncontrol, andpatienteducationconcerns See the SNMMI Guideline for General Imaging. Policies and procedures related to quality, patient education, infection control, and safety should be developed and implemented in accordance with good quality control practices. Quality control should also be done regularly to assure consistent, accurate physician interpretation of results. Equipment performance monitoring should be in accordance with a recognized accrediting organization. Documentation/reporting See the SNMMI Guideline for General Imaging for documentation/reporting requirements. Radiationsafety inimaging See the SNMMI Guideline for General Imaging. It is the position of SNMMI that patient exposure to ionizing radiation should be at the minimum level consistent with obtaining a diagnostic examination. Reduction in patient radiation exposure may be accomplished by administering less radiopharmaceutical when the technique or equipment used for imaging can support such an action. Each patient procedure is unique and the methodology to achieve minimum exposure while maintaining diagnostic accuracy needs to be viewed in this light. Radiopharmaceutical activity ranges outlined in this document should be considered as a guide. Dose-reduction techniques should be utilized when appropriate. The same principles should be applied when CT is used in a hybrid imaging procedure. CT acquisition protocols should be optimized to provide the information needed while minimizing patient radiation exposure. Minimizing radiation dose is especially important in children. Thebreastfeedingpatient See the Advisory Committee on the Medical Uses of Isotopes (ACMUI) guidelines.
BACKGROUND: To assess the accuracy of myocardial perfusion imaging (MPI) on a cadmium-zinc-telluride camera in detecting coronary artery disease (CAD) and predicting prognosis in older patients. METHODS: Six hundred and...BACKGROUND: To assess the accuracy of myocardial perfusion imaging (MPI) on a cadmium-zinc-telluride camera in detecting coronary artery disease (CAD) and predicting prognosis in older patients. METHODS: Six hundred and twenty-seven older patients (aged >70 years) and the same number of matched controls were submitted to exercise or vasodilator-stress MPI and coronary angiography. The rate-pressure product (RPP) reserve (stress/rest) was computed as a measure of cardiac workload during exercise. Ischemia was defined as a summed difference score (SDS) >3. Coronary stenoses >70% were considered obstructive. Patients were followed (mean 4.1 ± 2.4 years) for a composite of cardiovascular death, nonfatal myocardial infarction, and urgent revascularization (MACE). RESULTS: Obstructive CAD was revealed in 426/627 patients (68%) and 410/627 controls (65%). While in the overall population MPI showed a significant accuracy for detecting obstructive CAD (AUC: .79, 95% confidence interval [CI]: .77-.82; P < .001), test accuracy seemed to decrease with older age, with older patients showing lower specificity than controls (72% vs 64%, respectively; P = .002). This difference was exclusively limited to patients undergoing exercise-stress, whereby the overall test accuracy was significantly lower in older patients than controls (AUC: .82 vs .75; P = .03). Older patients attained a significantly lower peak workload (101 ± 26 W vs 111 ± 34 W; P < .001) and RPP reserve during exercise than controls (1.9 ± .9 vs 2.2 ± .7, P < .001), resulting in an independent predictor of reduced diagnostic specificity (odds ratio: .68, 95% CI: .50-.96; P = .027). At multivariable Cox regression analysis, a higher SDS was an independent predictor of major adverse cardiac events (MACE) (HR 1.11, 95% CI: 1.07-1.14; P < .001). CONCLUSIONS: In older patients, exercise-stress MPI shows a lower diagnostic accuracy than in controls because of an impaired exercise capacity.
BACKGROUND: Whether the prognostic value of heart rate responsiveness to pharmacological stress testing as assessed by stress or rest heart-rate ratio (HRR), adds prognostic value to contemporary PET MPI or varies accord...BACKGROUND: Whether the prognostic value of heart rate responsiveness to pharmacological stress testing as assessed by stress or rest heart-rate ratio (HRR), adds prognostic value to contemporary PET MPI or varies according to ejection fraction (EF) has not been well-studied. METHODS: Consecutive patients undergoing Rb-82 positron emission tomography (PET) between 2019 and 2024 with regadenoson stress testing were included. The Andersen-Gill extension of the Cox model, which incorporates potentially recurrent events, was used to evaluate the association between HRR and the primary outcome, a composite of death or heart failure (HF) hospitalization. Univariable and multivariable models adjusted for clinical and PET-related variables were used. Restricted cubic splines were used to allow for nonlinearity. Interquartile hazard ratios (HRs) comparing the 75th (referent) vs the 25th percentiles of HRR were reported. RESULTS: Over a median follow-up of 553 days (IQR: 232 to 941 days), a total of 1,288 primary outcome events occurred among 7,808 patients. A greater HRR was associated with a lower incidence of the primary outcome in both the univariable (HR: 0.28; 95% CI: 0.23 to 0.36) and multivariable (HR: 0.60; 95% CI: 0.48 to 0.75) models. The association of HRR with the primary outcome was greater at higher EFs (P for interaction: .02), with HRs of 0.69, 0.55, 0.49, and 0.47 at EFs of 40%, 50%, 60%, and 70% respectively. CONCLUSIONS: The prognostic value of HRR after pharmacological stress testing for death and HF hospitalization is most pronounced in patients with a preserved EF and is independent of traditional risk factors and PET parameters, including myocardial flow reserve.
DiGregorio H, Williams K, Weber B
… +1 more, Feher A
J Nucl Cardiol
· 2025 Nov · PMID 41033432
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Coronary microvascular dysfunction (CMVD) significantly contributes to increased cardiovascular morbidity and mortality in patients with autoimmune systemic inflammatory diseases. Clinicians should maintain a high index...Coronary microvascular dysfunction (CMVD) significantly contributes to increased cardiovascular morbidity and mortality in patients with autoimmune systemic inflammatory diseases. Clinicians should maintain a high index of suspicion for CMVD when discussing cardiovascular symptoms in this patient population. In symptomatic patients without obstructive coronary artery disease, diagnostic evaluation of CMVD should be considered carefully. In this review, we will outline the pathophysiology of CMVD, with an emphasis on the role of inflammation in the development and progression of microvascular disease. We will also review available noninvasive and invasive diagnostic testing for the detection of microvascular disease and discuss evidence-based strategies for managing CMVD in these complex patients.
Pascale R, Fernández-Hidalgo N, Tazza B
… +9 more, Bartoletti M, Bertolino L, Durante-Mangoni E, Roque Pérez A, Pizzi MN, Viale P, Giannella M, European Society of Clinical Microbiology and Infectious Diseases Study Group on Implant Associated Infections (ESGIAI), European Society of Clinical Microbiology and Infectious Diseases Study Group for Bloodstream Infections, Endocarditis and Sepsis (ESGBIES)
Miller RJH, Barrett O, Shanbhag A
… +14 more, Rozanski A, Dey D, Lemley M, Van Kriekinge SD, Kavanagh PB, Feher A, Miller EJ, Einstein AJ, Ruddy TD, Bateman T, Kaufmann PA, Liang JX, Berman DS, Slomka PJ
J Nucl Cardiol
· 2025 Nov · PMID 40939829
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BACKGROUND: In many contemporary laboratories, a completely normal stress perfusion single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is required for rest imaging cancelation. We hypothe...BACKGROUND: In many contemporary laboratories, a completely normal stress perfusion single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is required for rest imaging cancelation. We hypothesized that an artificial intelligence (AI)-derived coronary artery calcium (CAC) score of 0 from computed tomography attenuation correction (CTAC) scans obtained during hybrid SPECT/CT may identify additional patients at a low risk of major adverse cardiovascular events (MACEs) who could be selected for stress-only imaging. METHODS: Patients without known coronary artery disease who underwent SPECT/CT MPI and had stress total perfusion deficit (TPD) <5% were included. Stress TPD was categorized as no abnormality (stress TPD: 0%) or minimal abnormality (stress TPD: 1%-4%). CAC was automatically quantified from the CTAC scans. We evaluated associations with MACEs. RESULTS: In total, 6884 patients (49.4% males and median age: 63 years) were included. Of these, 9.7% experienced MACE (15% non-fatal myocardial infarction, 2.7% unstable angina, 38.5% coronary revascularization and 43.8% deaths). Compared to patients with TPD 0%, those with TPD 1%-4% and CAC 0 had lower MACE risk (hazard ratio [HR]: 0.58; 95% confidence interval [CI]: 0.45-0.76), while those with TPD 1%%-4% and CAC score>0 had a higher MACE risk (HR: 1.90; 95% CI: 1.56-2.30). Compared to canceling rest scans only in patients with normal perfusion (TPD 0%), by canceling rest scans in patients with CAC 0, more than twice as many rest scans (55% vs 25%) could potentially be canceled. CONCLUSION: Using an AI-derived CAC of 0 on CT scans with hybrid SPECT/CT in patients with a stress TPD <5% can double the proportion of patients in whom stress-only procedures could be safely performed.