18F-fluoride positron emission tomography for identification of ruptured and high-risk coronary atherosclerotic plaques: a prospective clinical trial

Background The use of non-invasive imaging to identify ruptured or high-risk coronary atherosclerotic plaques would represent a major clinical advance for prevention and treatment of coronary artery disease. We used combined PET and CT to identify ruptured and high-risk atherosclerotic plaques using the radioactive tracers F-18-sodium fluoride (F-18-NaF) and F-18-fluorodeoxyglucose (F-18-FDG). Methods In this prospective clinical trial, patients with myocardial infarction (n=40) and stable angina (n=40) underwent F-18-NaF and F-18-FDG PET-CT, and invasive coronary angiography. F-18-NaF uptake was compared with histology in carotid endarterectomy specimens from patients with symptomatic carotid disease, and with intravascular ultrasound in patients with stable angina. The primary endpoint was the comparison of F-18-fluoride tissue-to-background ratios of culprit and non-culprit coronary plaques of patients with acute myocardial infarction. Findings In 37 (93%) patients with myocardial infarction, the highest coronary F-18-NaF uptake was seen in the culprit plaque (median maximum tissue-to-background ratio: culprit 1.66 [IQR 1.40-2.25] vs highest non-culprit 1.24 [1.06-1.38], p<0.0001). By contrast, coronary F-18-FDG uptake was commonly obscured by myocardial uptake and where discernible, there were no differences between culprit and non-culprit plaques (1.71 [1.40-2.13] vs 1.58 [1.28-2.01], p=0.34). Marked F-18-NaF uptake occurred at the site of all carotid plaque ruptures and was associated with histological evidence of active calcification, macrophage infiltration, apoptosis, and necrosis. 18 (45%) patients with stable angina had plaques with focal F-18-NaF uptake (maximum tissue-to-background ratio 1.90 [IQR 1.61-2.17]) that were associated with more high-risk features on intravascular ultrasound than those without uptake: positive remodelling (remodelling index 1.12 [1.09-1.19] vs 1.01 [0.94-1.06]; p=0.0004), microcalcification (73% vs 21%, p=0.002), and necrotic core (25% [21-29] vs 18% [14-22], p=0.001). Interpretation F-18-NaF PET-CT is the first non-invasive imaging method to identify and localise ruptured and high-risk coronary plaque. Future studies are needed to establish whether this method can improve the management and treatment of patients with coronary artery disease.