Sodium-fluoride PET-CT for the non-invasive evaluation of coronary plaques in symptomatic patients with coronary artery disease: a cross-correlation study with intravascular ultrasound

OBJECTIVES: The aim of this study was to evaluate the (18)F-sodium fluoride ((18)F-NaF) coronary uptake compared to coronary intravascular ultrasound (IVUS) in patients with symptomatic coronary artery disease. BACKGROUND: (18)F-NaF PET enables the assessment of vascular osteogenesis by interaction with surface hydroxyapatite, while IVUS enables both identification and quantification of intra-plaque components. METHODS: Forty-four patients with symptomatic coronary artery disease were included in this prospective controlled trial, 32 of them (30 patients with unstable angina and 2 patients with stable angina), representing the final study cohort, got additional IVUS. All patients underwent cardiac (18)F-NaF PET/CT and IVUS within 2 days. (18)F-NaF maximum tissue-to-blood ratios (TBR(max)) were calculated for 69 coronary plaques and correlated with IVUS plaque classification. RESULTS: Significantly increased (18)F-NaF uptake ratios were observed in fibrocalcific lesions (meanTBR(max) = 1.42 ± 0.28), thin-cap atheroma with spotty calcifications (meanTBR(max) = 1.32 ± 0.23), and thick-cap mixed atheroma (meanTBR(max) = 1.28 ± 0.38), while fibrotic plaques showed no increased uptake (meanTBR(max) = 0.96 ± 0.18). The (18)F-NaF uptake ratio was consistently higher in atherosclerotic lesions with severe calcification (meanTBR(max) = 1.34 ± 0.22). The regional (18)F-NaF uptake was most likely localized in the border region of intensive calcification. Coronary lesions with positive (18)F-NaF uptake showed some increased high-risk anatomical features on IVUS in comparison to (18)F-NaF negative plaques. It included a significant severe plaque burden (70.1 ± 13.8 vs. 61.0 ± 13.8, p = 0.01) and positive remodeling index (1.03 ± 0.08 vs. 0.99 ± 0.07, p = 0.05), as well as a higher percentage of necrotic tissue (37.6 ± 13.3 vs. 29.3 ± 15.7, p = 0.02) in positive (18)F-NaF lesions. CONCLUSIONS: (18)F-NaF coronary uptake may provide a molecular insight for the characterization of coronary atherosclerotic lesions. Specific regional uptake is needed to be determined by histology. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s00259-018-4122-0) contains supplementary material, which is available to authorized users.