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{ 42 } State-of-the-art Nuclear Cardiac Imaging: Cardiac PET – Current Status in the UK and Future Directions Randeep K Kulshrestha, Parthiban Arumugam { 42 } IMAGING & ONCOLOGY 2013
Coronary artery disease (CAD) remains a major health concern within the UK causing approximately 80,000 deaths per year 1 . Early diagnosis and appropriate management is important to reduce mortality and morbidity secondary to CAD. There are several non invasive diagnostic modalities to detect CAD, including exercise testing, stress echocardiography, and perfusion MR (magnetic resonance). In addition, radionuclide myocardial perfusion imaging, including single photon emission tomography (SPECT) or positron emission tomography (PET) is very useful. SPECT is well established worldwide with a wealth of diagnostic and prognostic data on patients with and without CAD. PET is emerging as a genuine and worthy alternative to SPECT, especially since the increased availability of a generator-produced radionuclide, 82-Rubidium (82Rb). Although cardiac PET is rapidly growing worldwide, especially in the USA, there are relatively few centres in the UK currently performing cardiac PET. Cardiac PET has been shown to have equivalent or better diagnostic accuracy when compared to Cardiac SPECT and Cardiac MR 2 . There are also emerging data on the prognostic value related to PET perfusion imaging 3 . The focus of PET-CT scanning has been oncology within the UK, with funding from the National Cancer Network, and less on cardiac imaging and hence funding for this technique in these difficult economic times has been a major challenge, further limiting its potential, more widespread availability. Now there is increased interest in its applications for cardiac disease. A recent document produced by the Royal College of Physicians and Royal College of Radiologists Nuclear Medicine Working Party 4 regarding evidence-based indications for the use of PET-CT in the UK has acknowledged that both 13N-Ammonia and 82Rb are useful and superior to Technetium labelled SPECT agents for the assessment of myocardial perfusion. In addition, metabolic imaging with 18F-FDG (18F-fluorodeoxyglucose) is considered to be useful in the assessment of myocardial viability in patients with ischaemia-induced heart failure. The more widespread availability of PET-CT scanners in the UK, along with the availability of generator-produced 82Rb has made cardiac PET imaging feasible. General principles Cardiac PET requires the intravenous administration of a radioactive radionuclide on its own or tagged to a pharmaceutical which targets the heart. PET tracers are produced either in a regional cyclotron (ie particle accelerator used to produce short lived positron emitting isotopes) or locally in a generator 5 . 82Rb is generator produced and 15O-Water and 13N-Ammonia are cyclotron produced cardiac PET tracers. Depending on the myocardial extraction of the tracer, tracer delivery is proportional to cardiac blood flow. The most physiological tracer is 15O-Water, with tracer delivery being directly proportional to flow, but it is not possible to obtain clinical images practically, due to very quick equilibration between vascular and tissue compartments 6,7,8 . 13N-Ammonia, in turn, has a better extraction fraction than 82Rb and is more linear to the blood flow 9 . Due to practical advantages, which will be outlined later, 82Rb is however, the most widely used myocardial PET tracer. After injection, the PET tracer is taken up in the heart. Radioactive decay then occurs within the heart, whereupon a positron or positively charged “Having both PET and CT information avoids unnecessary invasive coronary artery catheterisations” IMAGING & ONCOLOGY 2013 { 43 }
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