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NaF-PET Imaging of Atherosclerosis Burden. J Imaging 2023; 9:jimaging9020031. [PMID: 36826950 PMCID: PMC9966512 DOI: 10.3390/jimaging9020031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/19/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
The method of 18F-sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT) of atherosclerosis was introduced 12 years ago. This approach is particularly interesting because it demonstrates microcalcification as an incipient sign of atherosclerosis before the development of arterial wall macrocalcification detectable by CT. However, this method has not yet found its place in the clinical routine. The more exact association between NaF uptake and future arterial calcification is not fully understood, and it remains unclear to what extent NaF-PET may replace or significantly improve clinical cardiovascular risk scoring. The first 10 years of publications in the field were characterized by heterogeneity at multiple levels, and it is not clear how the method may contribute to triage and management of patients with atherosclerosis, including monitoring effects of anti-atherosclerosis intervention. The present review summarizes findings from the recent 2¾ years including the ability of NaF-PET imaging to assess disease progress and evaluate response to treatment. Despite valuable new information, pertinent questions remain unanswered, not least due to a pronounced lack of standardization within the field and of well-designed long-term studies illuminating the natural history of atherosclerosis and effects of intervention.
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Parry R, Majeed K, Pixley F, Hillis GS, Francis RJ, Schultz CJ. Unravelling the role of macrophages in cardiovascular inflammation through imaging: a state-of-the-art review. Eur Heart J Cardiovasc Imaging 2022; 23:e504-e525. [PMID: 35993316 DOI: 10.1093/ehjci/jeac167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/31/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiovascular disease remains the leading cause of death and disability for patients across the world. Our understanding of atherosclerosis as a primary cholesterol issue has diversified, with a significant dysregulated inflammatory component that largely remains untreated and continues to drive persistent cardiovascular risk. Macrophages are central to atherosclerotic inflammation, and they exist along a functional spectrum between pro-inflammatory and anti-inflammatory extremes. Recent clinical trials have demonstrated a reduction in major cardiovascular events with some, but not all, anti-inflammatory therapies. The recent addition of colchicine to societal guidelines for the prevention of recurrent cardiovascular events in high-risk patients with chronic coronary syndromes highlights the real-world utility of this class of therapies. A highly targeted approach to modification of interleukin-1-dependent pathways shows promise with several novel agents in development, although excessive immunosuppression and resulting serious infection have proven a barrier to implementation into clinical practice. Current risk stratification tools to identify high-risk patients for secondary prevention are either inadequately robust or prohibitively expensive and invasive. A non-invasive and relatively inexpensive method to identify patients who will benefit most from novel anti-inflammatory therapies is required, a role likely to be fulfilled by functional imaging methods. This review article outlines our current understanding of the inflammatory biology of atherosclerosis, upcoming therapies and recent landmark clinical trials, imaging modalities (both invasive and non-invasive) and the current landscape surrounding functional imaging including through targeted nuclear and nanobody tracer development and their application.
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Affiliation(s)
- Reece Parry
- School of Medicine, University of Western Australia, Perth 6009, Australia.,Department of Cardiology, Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000, Australia
| | - Kamran Majeed
- School of Medicine, University of Western Australia, Perth 6009, Australia.,Department of Cardiology, Waikato District Health Board, Hamilton 3204, New Zealand
| | - Fiona Pixley
- School of Biomedical Sciences, Pharmacology and Toxicology, University of Western Australia, Perth 6009, Australia
| | - Graham Scott Hillis
- School of Medicine, University of Western Australia, Perth 6009, Australia.,Department of Cardiology, Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000, Australia
| | - Roslyn Jane Francis
- School of Medicine, University of Western Australia, Perth 6009, Australia.,Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Perth 6009, Australia
| | - Carl Johann Schultz
- School of Medicine, University of Western Australia, Perth 6009, Australia.,Department of Cardiology, Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000, Australia
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Bellinge JW, Francis RJ, Lee SC, Vickery A, Macdonald W, Gan SK, Chew GT, Phillips M, Lewis JR, Watts GF, Schultz CJ. The effect of Vitamin-K 1 and Colchicine on Vascular Calcification Activity in subjects with Diabetes Mellitus (ViKCoVaC): A double-blind 2x2 factorial randomized controlled trial. J Nucl Cardiol 2022; 29:1855-1866. [PMID: 33825140 DOI: 10.1007/s12350-021-02589-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 02/03/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is currently no treatment for attenuating progression of arterial calcification. 18F-sodium fluoride positron emission tomography (18F-NaF PET) locates regions of calcification activity. We tested whether vitamin-K1 or colchicine affected arterial calcification activity. METHODS 154 patients with diabetes mellitus and coronary calcification, as detected using computed tomography (CT), were randomized to one of four treatment groups (placebo/placebo, vitamin-K1 [10 mg/day]/placebo, colchicine [0.5 mg/day]/placebo, vitamin-K1 [10 mg/day]/ colchicine [0.5 mg/day]) in a double-blind, placebo-controlled 2x2 factorial trial of three months duration. Change in coronary calcification activity was estimated as a change in coronary maximum tissue-to-background ratio (TBRmax) on 18F-NaF PET. RESULTS 149 subjects completed follow-up (vitamin-K1: placebo = 73:76 and colchicine: placebo = 73:76). Neither vitamin-K1 nor colchicine had a statistically significant effect on the coronary TBRmax compared with placebo (mean difference for treatment groups 0·00 ± 0·16 and 0·01 ± 0·17, respectively, p > 0.05). There were no serious adverse effects reported with colchicine or vitamin-K1. CONCLUSIONS In patients with type 2 diabetes, neither vitamin-K1 nor colchicine significantly decreases coronary calcification activity, as estimated by 18F-NaF PET, over a period of 3 months. CLINICAL TRIAL REGISTRATION ACTRN12616000024448.
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Affiliation(s)
- Jamie W Bellinge
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Roslyn J Francis
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia
- Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Sing Ching Lee
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Alistair Vickery
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia
- Black Swan Health, Perth, Western Australia, Australia
| | - William Macdonald
- Department of Nuclear Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Seng Khee Gan
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Gerard T Chew
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Michael Phillips
- Harry Perkins Institute for Medical Research, and Centre for Medical Research, University of Western Australia and, Nedlands, Western Australia, Australia
| | - Joshua R Lewis
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
- Centre for Kidney Research, Children's Hospital Westmead, School of Public Health, University of Sydney, Westmead, New South Wales, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia
- Cardiometabolic service, Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Carl J Schultz
- School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia.
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia.
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Bellinge JW, Francis RJ, Lee SC, Bondonno NP, Sim M, Lewis JR, Watts GF, Schultz CJ. The effect of vitamin K1 on arterial calcification activity in subjects with diabetes mellitus: a post hoc analysis of a double-blind, randomized, placebo-controlled trial. Am J Clin Nutr 2022; 115:45-52. [PMID: 34637494 DOI: 10.1093/ajcn/nqab306] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/02/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Coronary and aortic artery calcifications are generally slow to develop, and their burden predicts cardiovascular disease events. In patients with diabetes mellitus, arterial calcification is accelerated and calcification activity can be detected using 18F-sodium fluoride positron emission tomography (18F-NaF PET). OBJECTIVES We aimed to determine whether vitamin K1 supplementation inhibits arterial calcification activity in individuals with diabetes mellitus. METHODS This was a post hoc analysis of the ViKCoVaC (effect of Vitamin-K1 and Colchicine on Vascular Calcification activity in subjects with Diabetes Mellitus) double-blind randomized controlled trial conducted in Perth, Western Australia. Individuals with diabetes mellitus and established coronary calcification (coronary calcium score > 10), but without clinical coronary artery disease, underwent baseline 18F-NaF PET imaging, followed by oral vitamin K1 supplementation (10 mg/d) or placebo for 3 mo, after which 18F-NaF PET imaging was repeated. We tested whether individuals randomly assigned to vitamin K1 supplementation had reduced development of new 18F-NaF PET positive lesions within the coronary arteries and aorta. RESULTS In total, 149 individuals completed baseline and follow-up imaging studies. Vitamin K1 supplementation independently decreased the odds of developing new 18F-NaF PET positive lesions in the coronary arteries (OR: 0.35; 95% CI: 0.16, 0.78; P = 0.010), aorta (OR: 0.27; 95% CI: 0.08, 0.94; P = 0.040), and in both aortic and coronary arteries (OR: 0.28; 95% CI: 0.13, 0.63; P = 0.002). CONCLUSIONS In individuals with diabetes mellitus, supplementation with 10 mg vitamin K1/d may prevent the development of newly calcifying lesions within the aorta and the coronary arteries as detected using 18F-NaF PET. Further long-term studies are needed to test this hypothesis.This trial was registered at anzctr.org.au as ACTRN12616000024448.
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Affiliation(s)
- Jamie W Bellinge
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Roslyn J Francis
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia.,Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Sing C Lee
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Nicola P Bondonno
- Institute for Nutrition Research, School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia.,School of Biomedical Sciences, University of Western Australia, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Marc Sim
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia.,Institute for Nutrition Research, School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Joshua R Lewis
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia.,Institute for Nutrition Research, School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia.,Centre for Kidney Research, Children's Hospital Westmead, School of Public Health, University of Sydney, Westmead, New South Wales, Australia
| | - Gerald F Watts
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia.,Cardiometabolic Service, Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Carl J Schultz
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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Bellinge JW, Schultz CJ. Optimizing arterial 18F-sodium fluoride positron emission tomography analysis. J Nucl Cardiol 2021; 28:1887-1890. [PMID: 31873832 DOI: 10.1007/s12350-019-01992-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 11/30/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Jamie W Bellinge
- School of Medicine, University of Western Australia, Perth, WA, Australia.
- Department of Cardiology, Royal Perth Hospital, 197 Wellington St, Perth, WA, 6000, Australia.
| | - Carl J Schultz
- School of Medicine, University of Western Australia, Perth, WA, Australia
- Department of Cardiology, Royal Perth Hospital, 197 Wellington St, Perth, WA, 6000, Australia
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Advances in Quantitative Analysis of 18F-Sodium Fluoride Coronary Imaging. Mol Imaging 2021; 2021:8849429. [PMID: 33746631 PMCID: PMC7953548 DOI: 10.1155/2021/8849429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/05/2020] [Indexed: 11/22/2022] Open
Abstract
18F-sodium fluoride (18F-NaF) positron emission tomography (PET) has emerged as a promising noninvasive imaging tool for the assessment of active calcification processes in coronary artery disease. 18F-NaF uptake colocalizes to high-risk and ruptured atherosclerotic plaques. Most recently, 18F-NaF coronary uptake was shown to be a robust and independent predictor of myocardial infarction in patients with advanced coronary artery disease. In this review, we provide an overview of the advances in coronary 18F-NaF imaging. In particular, we discuss the recently developed and validated motion correction techniques which address heart contractions, tidal breathing, and patient repositioning during the prolonged PET acquisitions. Additionally, we discuss a novel quantification approach—the coronary microcalcification activity (which has been inspired by the widely employed method in oncology total active tumor volume measurement). This new method provides a single number encompassing 18F-NaF activity within the entire coronary vasculature rather than just information regarding a single area of most intense tracer uptake.
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Majeed K, Bellinge JW, Butcher SC, Alcock R, Spiro J, Playford D, Hillis GS, Newby DE, Mori TA, Francis R, Schultz CJ. Coronary 18F-sodium fluoride PET detects high-risk plaque features on optical coherence tomography and CT-angiography in patients with acute coronary syndrome. Atherosclerosis 2020; 319:142-148. [PMID: 33358367 DOI: 10.1016/j.atherosclerosis.2020.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 11/08/2020] [Accepted: 12/11/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS 18F-Sodium Fluoride Positron Emission Tomography (18F-NaF PET) non-invasively detects micro-calcification activity, the earliest stage of atherosclerotic arterial calcification. We studied the association between coronary 18F-NaF uptake and high-risk plaque features on intra-coronary optical coherence tomography (OCT) and CT-angiography (CTCA) and the potential application to patient-level risk stratification. METHODS Sixty-two prospectively recruited patients with acute coronary syndrome (ACS) underwent multi-vessel OCT, 18F-NaF PET and CTCA. The maximum tissue to background ratio (TBRmax = standardised uptake value (SUV)max/SUVbloodpool) was measured in each coronary segment on 18F-NaF PET scans. High-risk plaque features on OCT and CTCA were compared in matched coronary segments. The number of patients testing positive (>2SD above the normal range) for micro-calcification activity was determined. RESULTS In 62 patients (age, mean ± standard deviation (SD) = 61 ± 9 years, 85% male) the coronary segments with elevated 18F-NaF uptake had higher lipid arc (LA) (median [25th-75th centile]: 74° [35°-117°] versus 48° [15°-83°], p=0.021), higher prevalence of macrophages [n(%): 37 (62%) versus 89 (39%), p=0.008] and lower plaque free wall (PFW) (50° [7°-110°] versus 94° [34°-180°], p=0.027) on OCT, and a higher total plaque burden (p=0.011) and higher dense calcified plaque burden (p= 0.001) on CTCA, when compared with 18F-NaF negative segments. Patients grouped by increasing number of coronary lesions positive for microcalcification activity (0,1, ≥2) showed decreasing plaque free wall, increasing calcification and increasing macrophages on OCT (respectively p=0.008, p < 0.001 and p=0.028). CONCLUSIONS 18F-NaF uptake is associated with high-risk plaque features on OCT and CTCA in a per-segment and per-patient analysis in subjects hospitalized for ACS.
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Affiliation(s)
- Kamran Majeed
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Jamie W Bellinge
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Steele C Butcher
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Richard Alcock
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Jon Spiro
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - David Playford
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Graham S Hillis
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - David E Newby
- Centre for Cardiovascular Science, Clinical Research Imaging Centre, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Trevor A Mori
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Roslyn Francis
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Nuclear Medicine Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Carl J Schultz
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia.
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Høilund-Carlsen PF, Sturek M, Alavi A, Gerke O. Atherosclerosis imaging with 18F-sodium fluoride PET: state-of-the-art review. Eur J Nucl Med Mol Imaging 2019; 47:1538-1551. [PMID: 31773235 PMCID: PMC7188711 DOI: 10.1007/s00259-019-04603-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/05/2019] [Indexed: 12/30/2022]
Abstract
Purpose We examined the literature to elucidate the role of 18F-sodium fluoride (NaF)-PET in atherosclerosis. Methods Following a systematic search of PubMed/MEDLINE, Embase, and Cochrane Library included articles underwent subjective quality assessment with categories low, medium, and high. Of 2811 records, 1780 remained after removal of duplicates. Screening by title and abstract left 41 potentially eligible full-text articles, of which 8 (about the aortic valve (n = 1), PET/MRI feasibility (n = 1), aortic aneurysms (n = 1), or quantification methodology (n = 5)) were dismissed, leaving 33 published 2010–2012 (n = 6), 2013–2015 (n = 11), and 2016–2018 (n = 16) for analysis. Results They focused on coronary (n = 8), carotid (n = 7), and femoral arteries (n = 1), thoracic aorta (n = 1), and infrarenal aorta (n = 1). The remaining 15 studies examined more than one arterial segment. The literature was heterogeneous: few studies were designed to investigate atherosclerosis, 13 were retrospective, 9 applied both FDG and NaF as tracers, 24 NaF only. Subjective quality was low in one, medium in 13, and high in 19 studies. The literature indicates that NaF is a very specific tracer that mimics active arterial wall microcalcification, which is positively associated with cardiovascular risk. Arterial NaF uptake often presents before CT-calcification, tends to decrease with increasing density of CT-calcification, and appears, rather than FDG-avid foci, to progress to CT-calcification. It is mainly surface localized, increases with age with a wide scatter but without an obvious sex difference. NaF-avid microcalcification can occur in fatty streaks, but the degree of progression to CT-calcification is unknown. It remains unknown whether medical therapy influences microcalcification. The literature held no therapeutic or randomized controlled trials. Conclusion The literature was heterogeneous and with few clear cut messages. NaF-PET is a new approach to detect and quantify microcalcification in early-stage atherosclerosis. NaF uptake correlates with cardiovascular risk factors and appears to be a good measure of the body’s atherosclerotic burden, potentially suited also for assessment of anti-atherosclerotic therapy. Electronic supplementary material The online version of this article (10.1007/s00259-019-04603-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Poul F Høilund-Carlsen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark. .,Research Unit of Clinical Physiology and Nuclear Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Michael Sturek
- Department of Anatomy, Cell Biology, Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abass Alavi
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark.,Research Unit of Clinical Physiology and Nuclear Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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