Cardiac PET Overview

Cardiac Positron Emission Tomography is emerging as the preferred test for the diagnosis of coronary artery disease (CAD). Despite the clear majority of nuclear cardiology procedures being performed on Single Photon Emission Computed Tomography (SPECT) imaging devices, there are several advantages of PET over SPECT: lower radiation dose to the patient, improved tracer kinetics, well established attenuation correction, coincidence detection of emitted events, and the ability to perform routine accurate coronary blood flow measurements.

These advantages correlate with improvements in procedure accuracy and sensitivity compared to SPECT, particularly for heavier patients, where breast, chest wall, and diaphragmatic attenuation interfere with conventional SPECT.

SUPERIOR DIAGNOSTIC ACCURACY

13N-ammonia cardiac PET imaging with coronary flow reserve (CFR) provides high spatial and contrast resolution images. The high-resolution PET detectors optimize the low kinetic energy of 13N-ammonia producing sharp myocardial perfusion images. The statistically high-count 13N-ammonia images of the myocardium are a result of the rapid clearance from blood pool, high first-pass extraction, high retention in the myocardium, and a relatively long physical half-life. 13N-ammonia consistently produces high-quality diagnostic studies regardless of patient size or gender.

Sensitivity Specificity Positive
predictive
value
Negative
Predictive
value
Accuracy
13N-ammonia MPI PET/CT with CFR 1 96 80 93 89 92
99mTc MPI CZT SPECT 2 87 67 92 53 83

POWERFUL PROGNOSTIC PREDICTOR

13N-ammonia with CFR is a strong predictor of patient outcomes. CFR offers improved risk stratification and has proven to be an independent predictor of adverse outcomes. The results of one study on the long-term prognostic value of 13N-ammonia with CFR demonstrated that an abnormal CFR, regardless of normal or abnormal perfusion images, was associated with higher adverse cardiac events. Conversely, a normal perfusion along with a normal CFR suggested a 3-year “warranty” period. 3

Annual Event Rate 3

PATIENT SAFETY

13N-ammonia offers the lowest radiation dose to the patient compared to all other SPECT and PET myocardial perfusion radiopharmaceuticals. High sensitivity PET and PET/CT scanners with 3D imaging capabilities allow for half-dose protocols and therefore can routinely provide a complete 13N-ammonia rest/stress CFR study with as little as 1 mSv. or less radiation exposure to the patient. 4

MPI Protocol 5 Average effective
MPI dose (mSv)
Average effective dose
from CT attenuation
correction (mSv)
Average total
effective dose (mSv)
201TI/99mTc-SPECT 29.3 0.5 30.3
Two-day 99mTc-SPECT 12.8-15.7 0.5 13.8-16.7
One-day 99mTc-SPECT 9.9-11.4 0.5 10.9-12.4
Stress-only 99mTc-SPECT 7.1-8.0 0.5 8.1-9.0
82Rb PET (2D) 3.7 0.5 4.2
13N-ammonia (2D) 2.2 0.5 2.7

COST EFFECTIVE

13N-ammonia with CFR provides significant value to the overall management of coronary artery disease (CAD). 13N-ammonia with CFR reduces unnecessary diagnostic procedures and can provide direction for both interventional and medical therapies. A study utilizing 13N-ammonia with CFR demonstrated that the 13N-ammonia CFR results had a direct impact on patient management in 78% of the patients while reducing the overall cost of managing coronary artery disease, even with an increase in the diagnostic imaging cost attributed to the 13N-ammonia PET/CT study. 6

Patient Management 6

REFERENCES & ARTICLES

References

  1. Fiechter et al. “Diagnostic Value of 13N-Ammonia Myocardial Perfusion PET: Added Value of Myocardial Flow Reserve” J Nucl Med 2012; 53:1230-1234
  2. Fiechter et al. “Nuclear myocardial perfusion imaging with a novel cadmium-zinc-telluride detector SPECT/CT device: first validation versus invasive coronary angiography” Eur J Nucl Med Mol Imaging 2011; 38:2025-2030
  3. Herzog et al. “Long-Term Prognostic Value of 13N-Ammonia Myocardial Perfusion Positron Emission Tomography” JACC 2009; 150-6
  4. Dorbala et al. “Approaches to Reducing Radiation Dose from Radionuclide Myocardial Perfusion Imaging” J Nucl Med 2015; 56:592-599
  5. Di Carli et al. “Cardiac PET/CT for the Evaluation of Known or Suspected Coronary Artery Disease” Radiographics. 2011;31:1239-1254
  6. Siegrist et al. “13N-ammonia myocardial perfusion imaging with a PET/CT scanner: impact on clinical decision making and cost-effectiveness” Eur J Nucl Med Mol Imaging 2008; 35(5):889-895

Articles

  1. Appropriate Use Criteria for Cardiac Radionuclide Imaging
  2. Diagnostic Accuracy of Rest/Stress ECG-gated 82Rb Myocardial Perfusion PET: Comparison with ECG-gated 99mTc Sestamibi SPECT
  3. Diagnostic Performance of PET in the Detection of Coronary Artery Disease: A Meta-Analysis
  4. 13N-ammonia Myocardial Perfusion Imaging with PET/CT Scanner: Impact on Clinical Decision Making and Cost Effectiveness
  5. Comparison of Cost-Effectiveness and Utility of Exercise ECG, Single Photon Emission Computed Tomography, Positron Emission Tomography, and Coronary Angiography for Diagnosis of Coronary Artery Disease
  6. Impact of Myocardial Perfusion Imaging with PET and 82Rb on Downstream Invasive Procedure Utilization, Costs, and Outcomes in Coronary Disease Management

GO WITH THE FLOW

Learn how coronary flow reserve is a key clinical application and diagnostic tool.

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