Will 18F-Sodium Fluoride PET-CT Imaging Be the Magic Bullet for Identifying Vulnerable Coronary Atherosclerotic Plaques?
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Myocardial infarction remains the commonest cause of premature death worldwide with coronary atherosclerotic plaque rupture often initiating the event. Despite an ever-expanding repertoire of cardiovascular imaging techniques, the race is still on to identify atherosclerotic lesions at high-risk of rupture: the so-called vulnerable plaque. Conventional imaging modalities such as stress testing and coronary angiography have consistently failed to identify such plaques, leading to the increasing appreciation that plaque rupture relates to factors other than just the degree of luminal stenosis. Indeed the focus has recently shifted to molecular imaging, in an attempt to directly target the pathological disease processes leading to rupture and thereby localize high-risk lesions. Histological data indicate that inflammation, necrosis and early stage microcalcification are key imaging targets by which to achieve this aim. Here, we discuss how these processes are related, focusing on the rationale and evidence supporting 18F-fluoride positron emission tomography as a novel non-invasive imaging technique for the identification of vulnerable atherosclerotic plaque.
KeywordsPositron emission tomography Computed tomography 18F-fluoride PET-CT imaging Coronary atherosclerosis Plaques
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 3.••Stone GW, Maehara A, Lansky AJ, de Bruyne B, Cristea E, Mintz GS, et al. A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011;364(3):226–35. This landmark study looked at the natural history of coronary atherosclerotic plaques using radiofrequency intravascular ultrasound and provided key pathological insights into our understanding of coronary disease.PubMedCrossRefGoogle Scholar
- 13.Kato K, Yonetsu T, Kim SJ, Xing L, Lee H, McNulty I, et al. Nonculprit plaques in patients with acute coronary syndromes have more vulnerable features compared with those with non-acute coronary syndromes: a 3-vessel optical coherence tomography study. Circ Cardiovasc Imaging. 2012;5(4):433–40.PubMedCrossRefGoogle Scholar
- 18.Radcliff K, Tang TB, Lim J, Zhang Z, Abedin M, Demer LL, et al. Insulin-like growth factor-I regulates proliferation and osteoblastic differentiation of calcifying vascular cells via extracellular signal-regulated protein kinase and phosphatidylinositol 3-kinase pathways. Circ Res. 2005;96(4):398–400.PubMedCrossRefGoogle Scholar
- 40.Even-Sapir E, Metser U, Mishani E, Lievshitz G, Lerman H, Leibovitch I. The detection of bone metastases in patients with high-risk prostate cancer: 99mTc-MDP Planar bone scintigraphy, single- and multi-field-of-view SPECT, 18F-fluoride PET, and 18F-fluoride PET/CT. J Nucl Med. 2006;47(2):287–97.PubMedGoogle Scholar
- 43.Agnese Irkle JLB, Skepper JN, Dweck MR, Joshi FR, Vesey AT, Bennett M, et al. 18F-NaF - a Specific Marker for Vascular Calcification in Atherosclerosis. Circulation. 2013;128:A17385.Google Scholar
- 45.Derlin T, Toth Z, Papp L, Wisotzki C, Apostolova I, Habermann CR, et al. Correlation of inflammation assessed by 18F-FDG PET, active mineral deposition assessed by 18F-fluoride PET, and vascular calcification in atherosclerotic plaque: a dual-tracer PET/CT study. J Nucl Med. 2011;52(7):1020–7.PubMedCrossRefGoogle Scholar
- 48.••Dweck MR, Jones C, Joshi N, Fletcher AM, Richardson H, White A, et al. Assessment of valvular calcification and inflammation by positron emission tomography in patients with aortic stenosis. Circulation. 2011. doi:10.1161/CIRCULATIONAHA.111.051052. This important study looks at 18F-fluoride uptake in aortic valve disease.Google Scholar
- 51.••Dweck MR, Chow MW, Joshi NV, Williams MC, Jones C, Fletcher AM, et al. Coronary arterial 18F-sodium fluoride uptake: a novel marker of plaque biology. J Am Coll Cardiol. 2012;59(17):1539–48. We first described the coronary uptake of 18F-fluoride in patients with or without aortic stenosis in this important paper.PubMedCrossRefGoogle Scholar
- 52.••Joshi NV, Vesey AT, Williams MC, Shah AS, Calvert PA, Craighead FH, et al. F-fluoride positron emission tomography for identification of ruptured and high-risk coronary atherosclerotic plaques: a prospective clinical trial. Lancet. 2013. doi:10.1016/S0140-6736(13)61754-7. In this paper, we show that 18F-fluoride can identify ruptured and high risk plaques in patients with myocardial infarction and stable angina. Furthermore, we characterise these plaques with intravascular imaging in patients with stable angina and with histology in patients undergoing carotid endartrectomy.PubMedGoogle Scholar