Imaging Inflammation Past, Present, and Future: Focus on Cardioimmunology

Growing evidence implicates the immune system as a critical mediator of cardiovascular disease progression and a viable therapeutic target. Increased inflammatory cell activity is seen in the full spectrum of disorders from early-stage atherosclerosis through myocardial infarction, cardiomyopathy, and chronic heart failure. Although therapeutic strategies to modulate inflammation have shown promise in preclinical animal models, efficacy in patients has been modest owing in part to the variable severity of inflammation across individuals. The diverse leukocyte subpopulations involved in different aspects of heart disease pose a challenge to effective therapy, wherein adverse and beneficial aspects of inflammation require appropriate balance. Noninvasive molecular imaging enables tissue-level interrogation of inflammatory cells in the heart and vasculature to provide mechanistic and temporal insights into disease progression. Although clinical imaging has relied on ¹⁸F-FDG as a nonselective and crude marker of inflammatory cell activity, new imaging probes targeting cell surface markers of different leukocyte subpopulations present the opportunity to visualize and quantify distinct phases of cardiac and vessel wall inflammation. Similarly, therapies are evolving to more effectively isolate adverse from beneficial cell populations. This parallel development of immunocardiology and molecular imaging provides the opportunity to refine treatments using imaging guidance, building toward mechanism-based precision medicine. Here, we discuss progress in molecular imaging of immune cells in cardiology from use of ¹⁸F-FDG in the past to the present expansion of the radiotracer arsenal and then to a future theranostic paradigm of tracer-therapy compound pairs with shared targets. We then highlight the critical experiments required to advance the field from preclinical concept to clinical reality.