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  • Review Article
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Uncovering atherosclerotic cardiovascular disease by PET imaging

Nature Reviews Cardiology (2024)Cite this article

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Abstract

Assessing atherosclerosis severity is essential for precise patient stratification. Specifically, there is a need to identify patients with residual inflammation because these patients remain at high risk of cardiovascular events despite optimal management of cardiovascular risk factors. Molecular imaging techniques, such as PET, can have an essential role in this context. PET imaging can indicate tissue-based disease status, detect early molecular changes and provide whole-body information. Advances in molecular biology and bioinformatics continue to help to decipher the complex pathogenesis of atherosclerosis and inform the development of imaging tracers. Concomitant advances in tracer synthesis methods and PET imaging technology provide future possibilities for atherosclerosis imaging. In this Review, we summarize the latest developments in PET imaging techniques and technologies for assessment of atherosclerotic cardiovascular disease and discuss the relationship between imaging readouts and transcriptomics-based plaque phenotyping.

Key points

  • Non-invasive imaging is essential for characterization of tissue-level disease states, and PET imaging in particular has tremendous potential for imaging atherosclerotic cardiovascular disease.

  • [18F]Fluorodeoxyglucose PET imaging has prognostic value for coronary events and can be used as a surrogate end point for cardiovascular disease in interventional studies.

  • Sodium [18F]fluoride is a stable marker of the risk of future cardiovascular events, and a high uptake of this tracer in the coronary arteries is associated with an increased risk of future myocardial infarction, whereas 68Ga-DOTATATE discriminates high-risk from low-risk coronary lesions and can inform on the effects of anti-inflammatory therapy.

  • Advanced omics techniques can provide important biological insights, including heterocellular interactions, on atherosclerotic plaque pathology, which could drive the development of new radiotracers.

  • Whole-body imaging has broadened our perspective on atherosclerotic cardiovascular disease by providing mechanistic insights into disease pathways and adding diagnostic value.

  • Advances in PET technology have the potential to improve sensitivity and specificity, increase information depth, increase quantification accuracy and lower radiation exposure.

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Fig. 1: Representative PET images of atherosclerosis.
Fig. 2: Imaging the systemic inflammatory effects that aggravate atherosclerosis.
Fig. 3: Technological advances to overcome limitations in PET imaging of atherosclerosis.
Fig. 4: PET tracer development and in vivo tracer labelling techniques.
Fig. 5: Advances in PET imaging technologies.

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Acknowledgements

A.M. received support from the Berta Ottenstein Program for Advanced Clinician Scientists, Faculty of Medicine, University of Freiburg, and the Deutsche Forschungsgemeinschaft (DFG; German Research Foundation) research grant Project #492563001, and is a member of SFB1425, funded by the DFG Project #422681845. M.M.T.v.L received support from the NIH grant R01HL169500. Z.A.F. received support from the NIH grants P01HL131478, P01AI168258, R01HL166720 and R01DA049547. The authors thank K. Joyes (Icahn School of Medicine at Mount Sinai, USA) for editing the manuscript before submission.

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  1. Department of Cardiology and Angiology, University Heart Center Freiburg–Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany

    Alexander Maier

  2. BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Abraham J. P. Teunissen, Sheqouia A. Nauta, Zahi A. Fayad & Mandy M. T. van Leent

  3. Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Abraham J. P. Teunissen, Sheqouia A. Nauta, Zahi A. Fayad & Mandy M. T. van Leent

  4. Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Abraham J. P. Teunissen, Sheqouia A. Nauta & Mandy M. T. van Leent

  5. Icahn Genomics Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Abraham J. P. Teunissen

  6. Cardiovascular Medicine and Immunology, Experimental Cardiovascular Immunology Laboratory, Mayo Clinic, Rochester, MN, USA

    Esther Lutgens

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A.M. and M.M.T.v.L. wrote the article. A.M., A.J.P.T., S.A.N., E.L., Z.A.F. and M.M.T.v.L. made substantial contributions to the discussion of content. All authors researched data for the article and reviewed and/or edited the manuscript before submission.

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Maier, A., Teunissen, A.J.P., Nauta, S.A. et al. Uncovering atherosclerotic cardiovascular disease by PET imaging. Nat Rev Cardiol (2024). https://doi.org/10.1038/s41569-024-01009-x

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