Uncovering atherosclerotic cardiovascular disease by PET imaging

Assessing atherosclerosis severity is essential for precise patient stratification. Specifically, there is a need to identify patients with residual inflammation because these patients remain at high risk of cardiovascular events despite optimal management of cardiovascular risk factors. Molecular imaging techniques, such as PET, can have an essential role in this context. PET imaging can indicate tissue-based disease status, detect early molecular changes and provide whole-body information. Advances in molecular biology and bioinformatics continue to help to decipher the complex pathogenesis of atherosclerosis and inform the development of imaging tracers. Concomitant advances in tracer synthesis methods and PET imaging technology provide future possibilities for atherosclerosis imaging. In this Review, we summarize the latest developments in PET imaging techniques and technologies for assessment of atherosclerotic cardiovascular disease and discuss the relationship between imaging readouts and transcriptomics-based plaque phenotyping. In this Review, van Leent and colleagues provide an overview of current PET imaging approaches for assessment of atherosclerotic cardiovascular disease, as well as of whole-body PET applications; discuss the link between imaging readouts and atherosclerotic plaque pathology; and highlight promising developments in PET systems and radiotracer synthesis. Key points Non-invasive imaging is essential for characterization of tissue-level disease states, and PET imaging in particular has tremendous potential for imaging atherosclerotic cardiovascular disease. [ 18 F]Fluorodeoxyglucose PET imaging has prognostic value for coronary events and can be used as a surrogate end point for cardiovascular disease in interventional studies. Sodium [ 18 F]fluoride is a stable marker of the risk of future cardiovascular events, and a high uptake of this tracer in the coronary arteries is associated with an increased risk of future myocardial infarction, whereas 68 Ga-DOTATATE discriminates high-risk from low-risk coronary lesions and can inform on the effects of anti-inflammatory therapy. Advanced omics techniques can provide important biological insights, including heterocellular interactions, on atherosclerotic plaque pathology, which could drive the development of new radiotracers. Whole-body imaging has broadened our perspective on atherosclerotic cardiovascular disease by providing mechanistic insights into disease pathways and adding di