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Updated: Aug 7, 2025
In Vivo Quantitative Assessment of Myocardial Structure, Function, Perfusion and Viability Using Cardiac Micro-computed Tomography
Published on: February 16, 2016
Myocardial Perfusion PET for the Detection and Reporting of Coronary Microvascular Dysfunction: A JACC:
Thomas H Schindler1, William F Fearon2, Matthieu Pelletier-Galarneau3
1Mallinckrodt Institute of Radiology, Division of Nuclear Medicine-Cardiovascular, Washington University in St Louis School of Medicine, St Louis, Missouri, USA.
Insights
Coronary microvascular dysfunction (CMD) causes angina in patients with clear arteries. Standardized cardiac PET imaging offers a noninvasive method to diagnose CMD, guiding better patient treatment and improving outcomes.
Area of Science:
- Cardiology
- Nuclear Medicine
- Diagnostic Imaging
Background:
- Angina and dyspnea in patients with nonobstructive coronary artery disease present diagnostic challenges.
- Coronary microvascular dysfunction (CMD) is increasingly recognized as a cause of these symptoms, affecting a significant portion of patients.
- Current diagnostic methods, including invasive angiography, have limitations in fully characterizing CMD.
Purpose of the Study:
- To establish standardized diagnostic, nomenclature, and reporting criteria for CMD using cardiac PET.
- To provide an overview of CMD pathophysiology, clinical evidence, and assessment methods.
- To differentiate CMD based on "classical" and "endogen" criteria derived from PET-derived myocardial blood flow (MBF) and myocardial flow reserve (MFR).
Main Methods:
- Utilizing positron emission tomography (PET) for absolute quantitative myocardial blood flow (MBF) assessment at rest and during hyperemia.
- Deriving myocardial flow reserve (MFR) from PET-derived MBF measurements.
- Convening an international expert panel to develop consensus criteria for CMD diagnosis and reporting.
Main Results:
- PET-determined quantitative MBF and MFR enable noninvasive detection and characterization of CMD.
- Standardized criteria are proposed for classifying normal coronary microvascular function and CMD based on "classical" (hyperemic MBF) and "endogen" (resting MBF) parameters.
- This standardization is crucial for accurate diagnosis of microvascular angina.
Conclusions:
- Standardized diagnosis and reporting of CMD using cardiac PET are critical for optimizing patient care and treatment decisions.
- Noninvasive assessment with PET-derived MBF and MFR facilitates individualized medical therapies for CMD.
- The proposed criteria aim to improve the diagnosis, management, and clinical trial outcomes for patients with CMD.
Abstract:
Angina pectoris and dyspnea in patients with normal or nonobstructive coronary vessels remains a diagnostic challenge. Invasive coronary angiography may identify up to 60% of patients with nonobstructive coronary artery disease (CAD), of whom nearly two-thirds may, in fact, have coronary microvascular dysfunction (CMD) that may account for their symptoms. Positron emission tomography (PET) determined absolute quantitative myocardial blood flow (MBF) at rest and during hyperemic vasodilation with subsequent derivation of myocardial flow reserve (MFR) affords the noninvasive detection and delineation of CMD. Individualized or intensified medical therapies with nitrates, calcium-channel blockers, statins, angiotensin-converting enzyme inhibitors, angiotensin II type 1-receptor blockers, beta-blockers, ivabradine, or ranolazine may improve symptoms, quality of life, and outcome in these patients. Standardized diagnosis and reporting criteria for ischemic symptoms caused by CMD are critical for optimized and individualized treatment decisions in such patients. In this respect, it was proposed by the cardiovascular council leadership of the Society of Nuclear Medicine and Molecular Imaging to convene thoughtful leaders from around the world to serve as an independent expert panel to develop standardized diagnosis, nomenclature and nosology, and cardiac PET reporting criteria for CMD. This consensus document aims to provide an overview of the pathophysiology and clinical evidence of CMD, its invasive and noninvasive assessment, standardization of PET-determined MBFs and MFR into "classical" (predominantly related to hyperemic MBFs) and "endogen" (predominantly related to resting MBF) normal coronary microvascular function or CMD that may be critical for diagnosis of microvascular angina, subsequent patient care, and outcome of clinical CMD trials.
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