The future of nuclear cardiac imaging: Reflection and a vision
The future of nuclear cardiac imaging: Reflection and a vision
Ami E. Iskandrian 0
MASNC 0 1
0 Reprint requests: Ami E. Iskandrian, MD, MACC, MASNC , Division of CV Diseases, Department of Medicine, University of Alabama at Birmingham , 318 LHRB/ 1900 University BLVD, Birmingham AL 35294 , USA
1 Division of CV Diseases, Department of Medicine, University of Alabama at Birmingham , Birmingham, AL , USA
My editor’s page will be excerpts from my plenary lecture given at the International Conference on Nuclear Cardiology and Cardiac CT, Vienna, Austria, on May 7, 2017.
It was indeed a pleasure and an honor to address the
audience of this meeting, which has a track record of
[ 20 years bringing people from around the world to
learn and share knowledge.
The predictions are that in the United States by
2035, [ 123 million will have hypertension; [ 24
million will have coronary artery disease (CAD); [ 11
million will have had a stroke; [ 9 million will have
heart failure; and[ 7 million will have atrial fibrillation.
That adds to a projected increase in heart disease costs
are to double from $555 billion in 2016 to $1.1 trillion in
2035! One would predict similar increases in both
developed and developing countries although Sweden
recently reported considerable declines in death from
any cause, death from cardiovascular disease, death
from coronary heart disease, and hospitalization for
cardiovascular disease between 199
8 and 2014
general population and in those with diabetes mellitus.1
This change and other changes (Table 1) imply that
imaging in general, and nuclear imaging especially will
continue to be a popular imaging modality for
sometimes to come.
It is very likely that positron emission tomography
(PET) use and measurement of myocardial blood flow
(MBF) will increase. A recent study may shed some
light, women though having less severe CAD by
coronary angiography than men, had worse outcome
especially those with reduced coronary flow reserve
ratio (ratio of hyperemic to rest MBF) measured by
PET.2 Historically, the prominent physician from
University of Paris wrote in 1902 ‘‘Another point to
remember is that angina pectoris is, like gout, a disease
of men, and not women. When it does manifest itself in
females, as is occasionally the case, it is often so
confused with the common and frequent pains in the left
side, due to flatulence or other causes, to which that sex
is especially prone, that its recognition may be a matter
of some difficulty.’’ His views were probably shared
until very recently by many physicians!
Though MBF use will increase (Figure 1), it does
not mean that all problems have been solved such
variability in measurements. Kitkungvan et al reported
test-retest methodological precision of global PET
myocardial perfusion by serial rest performed within
minutes apart is ± 10% while the day-to-different-day
biological plus methodological variability was ± 21%.
Further, the global myocardial perfusion at 8 minutes
after 4 minutes dipyridamole infusion was 10% higher
than at standard 4 minutes after dipyridamole.3 The
editorial by Beanlands concluded ‘‘… ultimately the
value of flow quantification must be shown in
multicenter clinical trials.’’4 Dilsizian et al concluded
‘‘…trust the quantitative analysis but verify it by visual
analysis.’’5 Clearly more studies are needed to address
the variability and impact of using different hardware,
software, stress agent, and protocol.
In additions to the tracers in Figure 1 and other
tracers to study cardiac metabolism and innervation,
there are a host of newer tracers; a partial list is provided
in Table 2 and many of these are presented in this
meeting. What is encouraging in the new list is that
these tracers will expand the use of nuclear imaging in
other cardiac conditions such as acute coronary
syndromes, myocarditis, chemotherapy-related
cardiotoxicity, and valvular heart diseases.
As we move forwards, it is equally important to
remain grounded and acknowledge the achievements
Marie and Pierre Curie (1903, 1911): Radioactive decay (Radium)
Henri Becquerel (1903): natural radioactivity (Uranium)
Albert Einstein (1921): Relation of matter to energy
Arthur Compton (1927): Scatter of radiation; Compton effect
Paul Dirac (1933): predicted existence of the positron (theoretical)
Carl Anderson (1936): detected antimatter (positron)
Ernest Lawrence (1939): Cyclotron
Georg von Hevesy (1943): tracer principles
John Cockcroft (1951): Linear accelerator
Emilio Serge (1959): Technetium
Robert Hofstadter (1961): Na-I scintillation detector
Henry Taube (1983): inorganic chemistry (technetium)
and shortcoming of past performances. Table 3 provides
a partial list of Noble laureates (courtesy of H William
Strauss, MD) and their contributions. On the downside,
Table 4 provides a partial list of products we studied but
It is likely that future research will be more complex
and demanding as it will require comparative
cost-effectiveness and hence involvement of broader
presentation of share-holders. Boden and Meadows
concluded ‘‘The need for updated models of risk in this
era of low event rates; a broader understanding of CAD
beyond the prevailing paradigm of obstructive epicardial
CAD; inclusion of novel, patient-centered and efficiency
outcomes; and the need for evidence of optimal post-test
treatment. Given the inherent variability in patient
phenotypes and clinical presentations, there is a
compelling need to translate group data derived from
randomized clinical trials to individual patient
management, such as distinguishing between modifiable and
non-modifiable risk factors, accounting for competing
comorbidities, and better defining patient-centered
The ACC/AHA and ESC guidelines and
appropriateness use criteria deserve are slowly but surely
changing to reflect recent evidence-based findings.8–13
Stirrup et al summarized the similarities and differences
between the 2 with regard to the utilization of imaging.14
There were two editorials in response to this report.15,16
Excerpts from the report by Christian are shown in
Finally, my reflections and conclusions as to the
future are summarized in Table 6.
In summary, the anticipated increase in number of
patients with ischemic heart disease in the future, the
expanded role of nuclear imaging in non-ischemic heart
diseases, the use of PET imaging and MBF, and the
availability of newer tracers, hardware and software are
only few of the reasons to be optimistic about the future
of nuclear cardiac imaging. Lessons learned from the
past experiences and newer guidelines and position
papers and statements are important. It is likely that
future studies are going to be more complex and
demanding and require broad participation of broader
spectrum of shareholders as well as across Atlantic
The Guidelines have an important role in the economics and practice of medicine in the USA
The Bayesian principles of pre-test likelihood of CAD are used in both guidelines; George Diamond must be
pleased to see they are the corner stones of the many guidelines * 40 years later!
Both guidelines emphasize the medical approach as first line therapy; Thanks to COURAGE trial
The USA is largely a fee for service enterprise (though it is changing!)
There is variability in the degree of socialization between European countries
In USA, increasingly hospitals are the dominant force in health care
Hospitals control the majority of physician practices and wield significant influence on physician behavior
Slight bias to perform coronary angiography for many intermediate- and high-risk patients in AHA/ACC guidelines
In 2011, when most of the guidelines were written, the highest fees for physicians and hospitals are in the cardiac
Guidelines in the grey zones retain flexibility in practice
There is a need for a scientific oversight ‘‘committee’’ to work with sponsors on future study designs
The study design and end-points are likely to be more complex and demanding
Comparative-effectiveness research requires a broad representation of shareholders
The goals should be set for long-term rather than short-term gains
The aim should be in the best interest of the field rather than individuals
There should be across Atlantic participation in these efforts
Industry and sponsors should understand that what is best for imaging in general is best for each as well; we grow
There should be organized efforts to raise necessary funds to pursue creative research (philanthropy, industry,
investors, and government agencies)
We need to promote the field world-wide and be inclusive
There are real reasons to be optimist for the future of our field
Ami E. Iskandrian, MD, MASNC Editor-in-Chief
None related to this presentation but the author is unpaid
consultant to Lantheus Pharma and is a Member of the
Imaging committee: GE-ADMIRE-ICD Trial
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2. Taqueti Viviany R , Shaw Leslee J , et al. Excess cardiovascular risk in women relative to men referred for coronary angiography is associated with severely impaired coronary flow reserve, not obstructive disease . Circulation . 2006 . doi: 10 .1161/ CIRCULATIONAHA.116.023266.
3. Kitkungvan D , Johnson NP , Roby AE , et al. Routine clinical quantitative rest stress myocardial perfusion for managing coronary artery disease . JACC . 2017 ; 10 : 565 - 77 .
4. Beanlands RS , Chong AY , deKemp RA . Clinical PET flow reserve imaging, is there precision to treat patients or populations? JACC . 2017 . doi: 10 .1016/j.jcmg. 2016 . 10 .004.
5. Dilsizian V , Chandrashekhar Y , Narula J. PET myocardial blood flow ''Trust, But Verify'' . JACC . 2017 . doi: 10 .1016/j.jcmg. 2017 . 03 .006.
6. Strauss HW , Narula J . Imaging vulnerable plaque a medical necessity or a scientific curiosity ? J Am Coll Cardiol . 2017 . doi: 10 .1016/j.jacc. 2017 . 03 .005.
7. Boden WE , Meadows JL . Role of imaging in the management of stable ischemic heart disease; an evolving paradigm shift . JACC . 2017 . doi: 10 .1016/j.jcmg. 2016 . 12 .009.
8. Windecker S , Kolh P , Alfonso F , et al. 2014 ESC/EACTS guidelines on myocardial revascularization . Eur Heart J . 2014 ; 35 : 2541 - 9 .
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10. Fihn SD , Blankenship JC , Alexander KP , et al. 2014 ACC/AHA/ AATS/PCNA/SCAI/ STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease . J Am Coll Cardiol . 2014 ; 64 : 1929 - 9 .
11. Greenland P , Alpert JS , Beller GA , Benjamin EJ , Budoff MJ , Fayad ZA , et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults . Circulation . 2010 ; 122 : e584 - 636 .
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15. Petretta M , Cuocolo A . Comparison of ESC and ACC/AHA guidelines for myocardial revascularization Are the differences clinically relevant? The European perspective . J Nuc Cardiol . 2017 ; 24 : 1057 - 1 .
16. Christian T. The unsaid word . J Nucl Cardiol . 2017 ; 24 : 1054 - 6 .