Additional Heparin Preadministration Improves Cardiac Glucose Metabolism Suppression over Low-Carbohydrate Diet Alone in <sup>18</sup>F-FDG PET Imaging

Scholtens, Asbjørn M.; Verberne, Hein J.; Budde, Ricardo P.J.; Lam, Marnix G. E. H.

doi:10.2967/jnumed.115.166884

Cited by 114 publications

(46 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Strategies using intravenous heparin at a dose of 50 IUÁkg -1 15 minutes prior to FDG injection in combination with either a low-carbohydrate diet ? 12 hour fast 11 or 18-hour fasting with low-carbohydrate diet 12 led to adequate suppression in 88%-100% of patients.…”

Section: See Related Article Pp 86-99mentioning

confidence: 99%

Challenges of cardiac inflammation imaging with F-18 FDG positron emission tomography

Bhambhvani

2017

Journal of Nuclear Cardiology

View full text Add to dashboard Cite

Reliable hot spot inflammation imaging with fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) in suspected cardiac infection, cardiac sarcoidosis, or vulnerable coronary plaque is only possible when physiologic myocardial FDG uptake can be adequately suppressed. The gamut of perfusion-metabolism patterns possible in cardiac sarcoidosis 1 combined with the erratic and real possibility of inadequate suppression of normal myocardial FDG uptake is a sure recipe for head scratching and challenging image interpretation. A number of preparation methods aimed at suppressing physiologic myocardial glucose utilization have been described without clear consensus on the optimal method. In the present issue of the Journal of Nuclear Cardiology, Osborne and colleagues (doi:10.1007/s12350-016-0502-7) review various preparation protocols and success rates achieved in published studies for FDG cardiac PET and provide useful practical recommendations.A brief overview of cardiomyocyte metabolism is essential to appreciate the challenges and rationale of interventions. The heart uses various substrates as energy sources including free fatty acids (FFAs), glucose, and lactate. In the fasting condition, the normal myocardium utilizes FFAs as the major energy source (90%). Other sources include glucose and lactate.2 Postmeals or in the dysfunctional myocardium (example ischemic heart disease), myocardial metabolism shifts to glucose per the glucose-fatty acid cycle.2,3 Elevated blood insulin and glucose levels with decreased FFAs lead to a relative rise in myocardial glucose consumption. In contrast, during fasting, there is an increase in FFAs with decrease in insulin and glucose levels, shifting myocardial energy consumption away from glucose and toward FFAs. Hence interventions that facilitate myocardial FFAs metabolism while at the same time suppress physiologic glucose metabolism are imperative for successful FDG PET cardiac inflammation imaging. These include avoidance of strenuous exercise prior to imaging (to prevent skeletal muscle glucose utilization), high-fat with low (less than 5 g)-or no carbohydrate diet (to increase blood FFAs and minimize glucose and insulin levels), addition of a high-fat drink to this diet prior to FDG injection (to elevate blood FFAs), fasting for 4-18 hours (to decrease blood glucose and insulin levels and increase FFAs), and certain pharmacologic maneuvers. The latter include unfractionated heparin which induces lipolysis and up to fivefold increase in blood FFAs 4 and calcium channel blockers which reduce myocardial FDG uptake.5 Most studies combine two or more interventions with the goal of complete suppression of normal cardiac FDG uptake.Tang and colleagues in a meta-analysis involving 16 studies and 559 patients evaluated for cardiac sarcoidosis examined various patient preparations that impact the diagnostic performance of FDG PET. They conclude that duration of fasting and heparin administration significantly affected the diagnostic odds ratio (P = .01 and .04, respec...

show abstract

Section: See Related Article Pp 86-99mentioning

confidence: 99%

Challenges of cardiac inflammation imaging with F-18 FDG positron emission tomography

Bhambhvani

2017

Journal of Nuclear Cardiology

View full text Add to dashboard Cite

show abstract

“…In the inflammatory cells, cellular activation increases both GLUT1 and GLUT3 but not GLUT4 expression. 18 F-FDG-6-P: FDG-6-phosphate, Glucose-6-P: glucose-6-phosphate, GLUT: glucose transporter protein, TCA: tricarboxylic acid cycle IU/kg, 15 min prior to FDG administration has been adopted, which increases serum FFA levels rapidly after heparin injection (9)(10)(11)(18)(19). On the other hand, although subject's body weights were not mentioned.…”

Section: Dietary Modification Prior To Fdg-petmentioning

confidence: 99%

Optimal Patient Preparation for Detection and Assessment of Cardiac Sarcoidosis by FDG-PET

Miyagawa

Tashiro

Watanabe

et al. 2017

Annals of Nuclear Cardiology

View full text Add to dashboard Cite

Abnormal uptake of 18 F-fluorodeoxyglucose (FDG) in the heart on positron emission tomography (PET) was recently included in the major criteria of diagnostic guidelines for cardiac sarcoidosis (CS). The high sensitivity but great variability in specificity in the diagnosis probably due to variable preparation methodologies of FDG-PET was reported. There are three main methods which have been reported to minimize physiological FDG uptake in the normal myocardium. A low carbohydrate diet on the day before PET with an overnight fasting more than 18-h achieves almost complete suppression of myocardial FDG uptake. Use of heparin pre-injection or high-fat diet preparation may enhance the suppressive effect. Serum FFA levels before PET imaging might be a biomarker of predicting the physiological FDG uptake in the myocardium.

show abstract

“…24 The study by Giorgetti et al in the current issue of the journal references prior studies that show improved myocardial glucose uptake suppression with dietary restriction in addition to prolonged fasting. 7,12,19 The investigators also provide further insight into the effect of pharmacologic interventions showing that anticoagulants other than the traditionally used UFH, i.e., LMWH and warfarin are also associated with satisfactory cardiomyocyte FDG suppression and optimal image quality in a significant majority of patients. 7 There are, however, certain limitations worth noting.…”

mentioning

confidence: 99%

“…24 An alternative approach would be a combination of high fat-low carbohydrate diet (one meal) followed by fasting and intravenous UFH just prior to FDG injection, which was shown to correlate with a success rate of 88% to 100% in two studies. 18,19,24 On the other hand, strategies which were not shown to correlate with high-quality FDG-PET imaging were fasting of short duration devoid of any dietary preparation, administration of a high-fat drink closely prior to the exam, and addition of calcium channel blocker, namely verapamil. 24 The study by Giorgetti et al in the current issue of the journal references prior studies that show improved myocardial glucose uptake suppression with dietary restriction in addition to prolonged fasting.…”

mentioning

confidence: 99%

Optimizing myocardial metabolism for fluorine-18 fluorodeoxyglucose positron emission tomography imaging of cardiac inflammation

Andrikopoulou

Bhambhvani

2018

Journal of Nuclear Cardiology

View full text Add to dashboard Cite

Inflammation-related hot spot imaging along with suppression of physiologic myocardial glucose metabolism forms the basis of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) imaging of inflammatory cardiomyopathies, infections of intracardiac devices, and prosthetic valves and vulnerable coronary plaques. Adequate attenuation of physiologic myocardial glucose uptake that ensures high-quality FDG-PET images, however, can be challenging, especially since glucose can be physiologically taken up by the cardiomyocytes under certain conditions. In order to maximize suppression of normal glucose uptake, a number of different interventions have been proposed and are utilized by PET laboratories, without there being a consensus on the most effective one.To better appreciate the different suppression techniques available, a basic understanding of myocardial metabolism is essential.1,2 A variety of different metabolic substrates can be utilized by the myocardium depending on fasting vs post-meal state and underlying viability. More specifically, during fasting state, there is a predominant (90%) utilization of free fatty acids (FFAs) and to a much lesser extent glucose and lactate.

show abstract

Additional Heparin Preadministration Improves Cardiac Glucose Metabolism Suppression over Low-Carbohydrate Diet Alone in ¹⁸F-FDG PET Imaging

Cited by 114 publications

References 26 publications

Challenges of cardiac inflammation imaging with F-18 FDG positron emission tomography

Challenges of cardiac inflammation imaging with F-18 FDG positron emission tomography

Optimal Patient Preparation for Detection and Assessment of Cardiac Sarcoidosis by FDG-PET

Optimizing myocardial metabolism for fluorine-18 fluorodeoxyglucose positron emission tomography imaging of cardiac inflammation

Contact Info

Product

Resources

About

Additional Heparin Preadministration Improves Cardiac Glucose Metabolism Suppression over Low-Carbohydrate Diet Alone in 18F-FDG PET Imaging

Cited by 114 publications

References 26 publications

Challenges of cardiac inflammation imaging with F-18 FDG positron emission tomography

Challenges of cardiac inflammation imaging with F-18 FDG positron emission tomography

Optimal Patient Preparation for Detection and Assessment of Cardiac Sarcoidosis by FDG-PET

Optimizing myocardial metabolism for fluorine-18 fluorodeoxyglucose positron emission tomography imaging of cardiac inflammation

Contact Info

Product

Resources

About

Additional Heparin Preadministration Improves Cardiac Glucose Metabolism Suppression over Low-Carbohydrate Diet Alone in ¹⁸F-FDG PET Imaging