Positron Emission Tomography in the Routine Management of Coronary Artery Disease

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  • A. Normal myocardial perfusion after dipyridamole stress.


  • B. Recurrent angina after bypass surgery with open grafts by arteriogram. PET shows a severe stress-induced, proximal septal defect due to progressive disease involving the first septal perforator proximal to the patent left anterior descending (LAD) graft.



  • C. Recurrent resting angina after a successful stent to the left circumflex (LCx) with no residual stenosis anywhere on arteriogram. PET shows a small severe defect in the distribution of a small first obtuse marginal branch with a flush occlusion at the stent site not visible on the arteriogram.



  • D. Reportedly 90% stenosis of LAD and 60% to 80% stenosis of LCx and RCA for which bypass surgery recommended. PET shows mild diffuse CAD without localized flow limiting stenosis. Review of arteriogram indicated overestimation of severity. Patient asymptomatic and well 12 years later on medical treatment.



  • E. Epigastric pain, CT scan showed no significant calcium, told had no heart disease. PET scan shows severe CAD, confirmed by arteriography.



  • F. Asymtomatic person with CT calcium score 2,839; arteriogram recommended. PET shows mild diffuse disease with no significant flow-limiting stenosis, thereby avoiding arteriogram.



  • G. Large anterior resting perfusion defect, reduced contraction, occluded LAD and question of transmural scar not suitable for revascularization.



  • H. Metabolic image with floro-deoxyglucose of the same patient as in panel G showing metabolically active, viable, hibernating myocardium in the underperfused area for which revascularization is indicated.



  • I. Familial CADÔÇöwoman with mild diffuse CAD and small acute non-transmural myocardial infarction (MI), wife of man in panel J.



  • J. Familial CADÔÇöman with mild CAD by PET, husband of woman in panel I.



  • K. Familal CADÔÇöa 46-year-old man with acute MI, son of patients in panel I and panel J. Of asymptomatic people who have a parent or sibling with CAD, 50% have dipyridamole-induced, statistically significant myocardial perfusion abnormalities outside 95% confidence intervals of normal controls, indicating preclinical CAD independent of other risk factors.



  • L. CT arteriogram showed '60% stenosisÔÇÖ with question of needing an invasive arteriogram. PET showed no significant flow-limiting stenosis thereby avoiding invasive arteriogram.



  • M. PET showed severe defects with myocardial steal after dipyridamople stress-indicating an occluded collateralized LCx, confirmed by arteriogram with no procedure done but intense pharmacologic and lifestyle program instituted.



  • N. PET of the same patient in panel M conducted four years later showing such well developed collaterals that dipyridamole stress caused no myocardial steal and only a mild perfusion defect.



  • O. Normal stress SPECT perfusion scan of a patient with risk factors, also had PET.



  • P. PET perfusion scan of the same patient in O showing a stress-induced defect typical of severe stenosis of the ramus intermedius starting at the basal anterior wall and extending infero-laterally.



Following Regression/Progression of CAD by PET During Intense Medical Treatment