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Rizwan S, Ayubcha C, Al-Daoud O, Al-Atout M, Amiruddin R, Werner TJ, Alavi A. PET imaging of atherosclerosis: artificial intelligence applications and recent advancements. Nucl Med Commun 2025; 46:503-514. [PMID: 40143664 DOI: 10.1097/mnm.0000000000001973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2025]
Abstract
PET imaging has become a valuable tool for assessing atherosclerosis by targeting key processes such as inflammation and microcalcification. Among available tracers, 18F-sodium fluoride has demonstrated superior performance compared to 18F-fluorodeoxyglucose, particularly in detecting coronary artery disease. However, the role of other tracers remains underexplored, requiring further validation. Emerging technologies such as artificial intelligence show potential in enhancing diagnostic speed and accuracy. Furthermore, the integration of the Alavi-Carlsen Calcification Score offers a novel approach to evaluating global disease burden, presenting a more clinically applicable method for predicting outcomes. Techniques such as total-body PET provide faster and more comprehensive imaging of the entire vascular system with reduced radiation exposure, representing a significant advancement in early detection and intervention. The combination of molecular imaging and advanced computational tools may revolutionize the management of atherosclerosis, facilitating earlier identification of at-risk individuals and improving long-term cardiovascular outcomes.
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Affiliation(s)
- Shaheer Rizwan
- Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Cyrus Ayubcha
- Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Omar Al-Daoud
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mamdouh Al-Atout
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raisa Amiruddin
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Hommels TM, Hermanides RS, Fabris E, Kedhi E. Exploring new insights in coronary lesion assessment and treatment in patients with diabetes mellitus: the impact of optical coherence tomography. Cardiovasc Diabetol 2023; 22:123. [PMID: 37226183 DOI: 10.1186/s12933-023-01844-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
In this review, we summarise new insights into diagnostic approaches and treatment strategies for coronary artery disease (CAD) in patients with diabetes mellitus (DM). Despite the improvements in therapy, the clinical management of DM patients remains challenging as they develop more extensive CAD at a younger age and consistently have worse clinical outcomes than non-DM patients. Current diagnostic modalities as well as revascularisation treatments mainly focus on ischemic lesions. However, the impact of plaque morphology and composition are emerging as strong predictors of adverse cardiac events even in the absence of identified ischemia. In particular, the presence of vulnerable plaques such as thin-cap fibroatheroma (TCFA) lesions has been identified as a very strong predictor of future adverse events. This emphasises the need for an approach combining both functional and morphological methods in the assessment of lesions. In particular, optical coherence tomography (OCT) has proven to be a valuable asset by truly identifying TCFAs. New treatment strategies should consist of individualised and advanced medical regimens and may evolve towards plaque sealing through percutaneous treatment.
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Affiliation(s)
| | | | - Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Elvin Kedhi
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Poniatowskiego 15, 40-055, Katowice, Poland.
- Department of Cardiology, Hôpital Erasme, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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3
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Henein MY, Vancheri S, Longo G, Vancheri F. The Role of Inflammation in Cardiovascular Disease. Int J Mol Sci 2022; 23:12906. [PMID: 36361701 PMCID: PMC9658900 DOI: 10.3390/ijms232112906] [Citation(s) in RCA: 277] [Impact Index Per Article: 92.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 07/21/2023] Open
Abstract
Atherosclerosis is a chronic inflammatory disease, in which the immune system has a prominent role in its development and progression. Inflammation-induced endothelial dysfunction results in an increased permeability to lipoproteins and their subendothelial accumulation, leukocyte recruitment, and platelets activation. Recruited monocytes differentiate into macrophages which develop pro- or anti-inflammatory properties according to their microenvironment. Atheroma progression or healing is determined by the balance between these functional phenotypes. Macrophages and smooth muscle cells secrete inflammatory cytokines including interleukins IL-1β, IL-12, and IL-6. Within the arterial wall, low-density lipoprotein cholesterol undergoes an oxidation. Additionally, triglyceride-rich lipoproteins and remnant lipoproteins exert pro-inflammatory effects. Macrophages catabolize the oxidized lipoproteins and coalesce into a lipid-rich necrotic core, encapsulated by a collagen fibrous cap, leading to the formation of fibro-atheroma. In the conditions of chronic inflammation, macrophages exert a catabolic effect on the fibrous cap, resulting in a thin-cap fibro-atheroma which makes the plaque vulnerable. However, their morphology may change over time, shifting from high-risk lesions to more stable calcified plaques. In addition to conventional cardiovascular risk factors, an exposure to acute and chronic psychological stress may increase the risk of cardiovascular disease through inflammation mediated by an increased sympathetic output which results in the release of inflammatory cytokines. Inflammation is also the link between ageing and cardiovascular disease through increased clones of leukocytes in peripheral blood. Anti-inflammatory interventions specifically blocking the cytokine pathways reduce the risk of myocardial infarction and stroke, although they increase the risk of infections.
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Affiliation(s)
- Michael Y. Henein
- Institute of Public Health and Clinical Medicine, Umea University, 90187 Umea, Sweden
- Institute of Environment & Health and Societies, Brunel University, Middlesex SW17 0RE, UK
- Molecular and Clinical Sciences Research Institute, St. George’s University, London UB8 3PH, UK
| | - Sergio Vancheri
- Interventional Neuroradiology Department, Besançon University Hospital, 25000 Besançon, France
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, 93100 Caltanissetta, Italy
| | - Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, 93100 Caltanissetta, Italy
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4
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Dawson LP, Layland J. High-Risk Coronary Plaque Features: A Narrative Review. Cardiol Ther 2022; 11:319-335. [PMID: 35731471 PMCID: PMC9381667 DOI: 10.1007/s40119-022-00271-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022] Open
Abstract
Advances in coronary plaque imaging over the last few decades have led to an increased interest in the identification of novel high-risk plaque features that are associated with cardiovascular events. Existing practices focus on risk stratification and lipid monitoring for primary and secondary prevention of cardiac events, which is limited by a lack of assessment and treatment of vulnerable plaque. In this review, we summarize the multitude of studies that have identified plaque, haemodynamic and patient factors associated with risk of acute coronary syndrome. Future progress in multi-modal imaging strategies and in our understanding of high-risk plaque features could expand treatment options for coronary disease and improve patient outcomes.
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Affiliation(s)
- Luke P Dawson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Jamie Layland
- Department of Medicine, Monash University, Clayton campus, Melbourne, VIC, Australia. .,Department of Cardiology, Peninsula Health, 2 Hastings Rd, Frankston, VIC, 3199, Australia.
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5
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Tomaniak M, Katagiri Y, Modolo R, de Silva R, Khamis RY, Bourantas CV, Torii R, Wentzel JJ, Gijsen FJH, van Soest G, Stone PH, West NEJ, Maehara A, Lerman A, van der Steen AFW, Lüscher TF, Virmani R, Koenig W, Stone GW, Muller JE, Wijns W, Serruys PW, Onuma Y. Vulnerable plaques and patients: state-of-the-art. Eur Heart J 2021; 41:2997-3004. [PMID: 32402086 DOI: 10.1093/eurheartj/ehaa227] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 03/26/2020] [Indexed: 01/21/2023] Open
Abstract
Despite advanced understanding of the biology of atherosclerosis, coronary heart disease remains the leading cause of death worldwide. Progress has been challenging as half of the individuals who suffer sudden cardiac death do not experience premonitory symptoms. Furthermore, it is well-recognized that also a plaque that does not cause a haemodynamically significant stenosis can trigger a sudden cardiac event, yet the majority of ruptured or eroded plaques remain clinically silent. In the past 30 years since the term 'vulnerable plaque' was introduced, there have been major advances in the understanding of plaque pathogenesis and pathophysiology, shifting from pursuing features of 'vulnerability' of a specific lesion to the more comprehensive goal of identifying patient 'cardiovascular vulnerability'. It has been also recognized that aside a thin-capped, lipid-rich plaque associated with plaque rupture, acute coronary syndromes (ACS) are also caused by plaque erosion underlying between 25% and 60% of ACS nowadays, by calcified nodule or by functional coronary alterations. While there have been advances in preventive strategies and in pharmacotherapy, with improved agents to reduce cholesterol, thrombosis, and inflammation, events continue to occur in patients receiving optimal medical treatment. Although at present the positive predictive value of imaging precursors of the culprit plaques remains too low for clinical relevance, improving coronary plaque imaging may be instrumental in guiding pharmacotherapy intensity and could facilitate optimal allocation of novel, more aggressive, and costly treatment strategies. Recent technical and diagnostic advances justify continuation of interdisciplinary research efforts to improve cardiovascular prognosis by both systemic and 'local' diagnostics and therapies. The present state-of-the-art document aims to present and critically appraise the latest evidence, developments, and future perspectives in detection, prevention, and treatment of 'high-risk' plaques occurring in 'vulnerable' patients.
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Affiliation(s)
- Mariusz Tomaniak
- Department of Cardiology, Erasmus Medical Centre, Thorax Centre, Rotterdam, The Netherlands.,First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Yuki Katagiri
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rodrigo Modolo
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Cardiology Division, Department of Internal Medicine, University of Campinas (UNICAMP), Campinas, Brazil
| | - Ranil de Silva
- National Heart and Lung Institute, Imperial College London, London, UK.,NIHR Cardiovascular Biomedical Research Unit, Institute of Cardiovascular Medicine and Science, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ramzi Y Khamis
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Christos V Bourantas
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London EC1A 7BE, UK.,William Harvey Research Institute, Queen Mary University London, Charterhouse Square, London EC1M 6BQ, UK.,Institute of Cardiovascular Sciences, University College London, 62 Huntley St, Fitzrovia, London WC1E 6DD, UK
| | - Ryo Torii
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Frank J H Gijsen
- Department of Biomedical Engineering, Erasmus Medical Centre, Thorax Centre, Rotterdam, The Netherlands
| | - Gijs van Soest
- Department of Cardiology, Biomedical Engineering, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Peter H Stone
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nick E J West
- Department of Interventional Cardiology, Royal Papworth Hospital, Papworth Rd, Trumpington, Cambridge CB2 0AY, UK
| | - Akiko Maehara
- Division of Cardiology, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.,Clinical Trials Centre, Cardiovascular Research Foundation, New York, NY, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Antonius F W van der Steen
- Department of Cardiology, Biomedical Engineering, Erasmus Medical Centre, Rotterdam, The Netherlands.,Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,Department of Imaging Physics, Faculty of Applied Sciences, Delft University of Technology, Delft, The Netherlands
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospital Trust, Imperial College London, , London, UK.,Centre for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | | | - Wolfgang Koenig
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany.,Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Gregg W Stone
- Division of Cardiology, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.,Clinical Trials Centre, Cardiovascular Research Foundation, New York, NY, USA
| | - James E Muller
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, Ireland.,Saolta University Healthcare Group, Galway, Ireland
| | - Patrick W Serruys
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway, Ireland
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6
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Henein MY, Vancheri S, Bajraktari G, Vancheri F. Coronary Atherosclerosis Imaging. Diagnostics (Basel) 2020; 10:65. [PMID: 31991633 PMCID: PMC7168918 DOI: 10.3390/diagnostics10020065] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 02/05/2023] Open
Abstract
Identifying patients at increased risk of coronary artery disease, before the atherosclerotic complications become clinically evident, is the aim of cardiovascular prevention. Imaging techniques provide direct assessment of coronary atherosclerotic burden and pathological characteristics of atherosclerotic lesions which may predict the progression of disease. Atherosclerosis imaging has been traditionally based on the evaluation of coronary luminal narrowing and stenosis. However, the degree of arterial obstruction is a poor predictor of subsequent acute events. More recent techniques focus on the high-resolution visualization of the arterial wall and the coronary plaques. Most acute coronary events are triggered by plaque rupture or erosion. Hence, atherosclerotic plaque imaging has generally focused on the detection of vulnerable plaque prone to rupture. However, atherosclerosis is a dynamic process and the plaque morphology and composition may change over time. Most vulnerable plaques undergo progressive transformation from high-risk to more stable and heavily calcified lesions, while others undergo subclinical rupture and healing. Although extensive plaque calcification is often associated with stable atherosclerosis, the extent of coronary artery calcification strongly correlates with the degree of atherosclerosis and with the rate of future cardiac events. Inflammation has a central role in atherogenesis, from plaque formation to rupture, hence in the development of acute coronary events. Morphologic plaque assessment, both invasive and non-invasive, gives limited information as to the current activity of the atherosclerotic disease. The addition of nuclear imaging, based on radioactive tracers targeted to the inflammatory components of the plaques, provides a highly sensitive assessment of coronary disease activity, thus distinguishing those patients who have stable disease from those with active plaque inflammation.
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Affiliation(s)
- Michael Y. Henein
- Institute of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden; (M.Y.H.); (G.B.)
- Departments of Fluid Mechanics, Brunel University, Middlesex, London UB8 3PH, UK
- Molecular and Nuclear Research Institute, St George’s University, London SW17 0RE, UK
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Gani Bajraktari
- Institute of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden; (M.Y.H.); (G.B.)
- Medical Faculty, University of Prishtina, 10000 Prishtina, Kosovo
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo
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