Cardiac PET/CT of Coronary Artery Disease

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:
[Note: Discipline-specific Targeted CE credits may be less than the total Category A credits approved for this course.]

Cardiac-Interventional Radiography: 1.50
Procedures: 1.50
Diagnostic and Conduction System Studies: 1.50

Computed Tomography: 1.50
Procedures: 1.50
Neck and Chest: 1.50

Nuclear Medicine Technology: 3.00
Procedures: 3.00
Cardiac Procedures: 3.00

Registered Radiologist Assistant: 2.00
Procedures: 2.00
Thoracic Section: 2.00

Outline

1. Introduction
2. Technical Aspect of Myocardial Perfusion PET
   1. Advantages of PET
   2. Imaging Agents for Clinical Use
   3. Advances in PET Technology
   4. Optimized Protocols for Myocardial Perfusion Imaging
   5. Radiation Dosimetry
   6. Recognizing and Preventing Imaging Artifacts at Cardiac PET/CT
3. Diagnostic and Prognostic Performance of Myocardial Perfusion PET
   1. Comparison with SPECT
   2. Detection of Multivessel CAD
   3. Quantification of Left Ventricular Function
   4. Quantification of Myocardial Blood Flow and Flow Reserve
   5. Risk Prediction
   6. Improvement of Risk Stratification with CFR Estimates
4. Emerging Clinical Role of Integrated PET/CT
   1. Potential Added Value of CAC Score in Patients with Normal Myocardial Perfusion
   2. Potential Added Value of Coronary CT Angiography in Patients with Equivocal Myocardial Perfusion PET Findings
   3. Potential Added Value of Myocardial Perfusion PET in Patients with Apparent CAD at Coronary CT Angiography
   4. Customization of Protocols
5. Conclusions

Objectives

Upon completion of this course, students will:

1. identify the advantages of PET cardiac imaging over SPECT cardiac imaging
2. be familiar with the particles detected in PET image creation
3. know the advantages and disadvantages of Rubidium 82 for PET MPI
4. know the advantages and disadvantages of Nitrogen 13 Ammonia for PET MPI
5. know the currently reported advantages and disadvantages of ¹⁸F flurpiridaz for PET MPI
6. be familiar with recent PET hardware and software improvements over prior generation PET systems
7. be familiar with the phenomenon known as “cardiac creep” and how it can affect MPI
8. understand the benefits of list mode PET imaging
9. know the different CT acquisition options for a PET attenuation correction CT series
10. be familiar with the acquisition times for PET MPI imaging
11. know the prep medications for CT angiography and the reasons for their usage
12. be familiar with the properties of cardiac stress agents
13. be familiar with the contraindications of cardiac stress agents
14. be familiar with the patient dose comparison among various PET and SPECT MPI studies
15. know causes for PET MPI artifacts due to CT transmission and PET emission misalignment
16. be familiar with the PET MPI accuracy statistics the article cites
17. define false positive for MPI
18. be familiar with the major causes of false positive and false negative results of MPI exams
19. be familiar with sensitivity, specificity, accuracy, and positive and negative predictive values
20. be familiar with the accuracy of PET MPI versus SPECT MPI
21. recognize the manifestations of balanced coronary ischemia
22. be familiar with normal LVEF stress response compared to abnormal LVEF stress response
23. understand the relationship between angiographic CAD and stress-induced LVEF change
24. know the method(s) utilized in PET assessment of multi-vessel CAD
25. know the relationship between PET coronary vasodilator reserve estimates and stenosis severity
26. understand PET MPI quantitation limitations and exams that may help in these situations
27. understand the implications of increasing extent and severity of PET MPI perfusion defects
28. understand how an increase in stress perfusion defects’ severity affects mortality prediction
29. recognize the prognostic information relationship between LVEF and stress MPI
30. know what determines patient pre-MPI likelihood of CAD
31. know at what pretest disease probability diagnostic examinations are most useful
32. understand the value of CFR estimation in patients with known or suspected CAD
33. be familiar with the factors incorporated into the Framingham scoring system
34. know the limitations of the Framingham scoring system
35. be familiar with the benefits of integrated PET/CT for cardiac imaging
36. understand the rationale for including CT CAC scoring with PET MPI
37. know the possible benefits of integrated PET/CT assessment of MPI and CAC scoring
38. know the HU groups for the Agatston method of calcium scoring
39. understand the drawbacks of Agatston calcium scoring
40. be familiar with the factors that confound the link between impaired CFR and obstructive epicardial disease
41. know how CTA can increase the specificity and PPV of PET CFR measurements
42. be familiar with treatment regimens for epicardial stenosis and impaired microvascular function
43. be familiar with the limitations of coronary CTA and how PET MPI can complement this exam
44. know the benefits of PET MPI as an adjunct exam to coronary CTA
45. be familiar with the considerations of creating different cardiac assessment protocols