Impact of Patient Preparation on the Diagnostic Performance of 18F-FDG PET in Cardiac Sarcoidosis

Tang, Reuben; Wang, Jeffrey Tzu-Yu; Wang, Louis; Le, Ken; Huang, Yeqian; Hickey, Adam; Emmett, Louise

doi:10.1097/rlu.0000000000001063

Cited by 75 publications

(38 citation statements)

References 28 publications

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“…They conclude that duration of fasting and heparin administration significantly affected the diagnostic odds ratio (P = .01 and .04, respectively), whereas a high fat low cholesterol diet did not have a significant effect (P = .17). 6 Nonspecific findings that may indicate failed suppression, and/or physiologic uptake and make image interpretation challenging included diffuse myocardial activity exceeding liver uptake or uptake in the lateral wall and/or ring shaped/circumferential basal uptake (Nensa et al doi: 10.1007/s12350-016-0443-1) 7 or papillary muscle uptake. 8,9 Diffuse FDG uptake in the entire left ventricular wall without focal uptake generally does not indicate disease as cardiac sarcoidosis is histopathologically known to be localized and not diffuse.…”

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

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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...

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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

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“…A fasting period of at least 12 hours, [1][2][3][4] as well as low-carbohydrate diet, [5][6][7][8][9][10][11][12] have been proven beneficial for decreasing the normal myocardial uptake of 18 Ffluorodeoxyglucose ( 18 F-FDG) and for enhancing the detectability of inflammatory and/or infectious heart diseases by 18 F-FDG positron emission tomography ( 18 F-FDG-PET). Unfortunately, none of these previously reported protocols enable the complete and consistent suppression of the cardiac uptake of 18 F-FDG.…”

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confidence: 99%

A 1-week extension of a ketogenic diet provides a further decrease in myocardial 18F-FDG uptake and a high detectability of myocarditis with FDG-PET

Clément

Boutley

Poussier

et al. 2020

Journal of Nuclear Cardiology

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confidence: 99%

“…25 A total of 16 studies and 559 patients were included in the final analysis, which showed that intravenous heparin and duration of fasting were positively associated with the diagnostic odds ratio (coefficient, 2.90; P = 0.04 and coefficient, 0.282; P = 0.01 respectively), as opposed to a high fat-low carb dietary preparation (coefficient, 1.71; P = 0.17). 25 Despite its thought-provoking findings, the meta-analysis did have some noteworthy limitations. First, it only included studies assessing patients with suspected or known sarcoidosis; second, the lack of a diagnostic reference standard for cardiac sarcoidosis makes the findings on sensitivity and specificity of FDG-PET somewhat challenging to interpret; and third, the majority of the studies included were small and the preparation methods employed were widely variable.…”

mentioning

confidence: 99%

“…First, it only included studies assessing patients with suspected or known sarcoidosis; second, the lack of a diagnostic reference standard for cardiac sarcoidosis makes the findings on sensitivity and specificity of FDG-PET somewhat challenging to interpret; and third, the majority of the studies included were small and the preparation methods employed were widely variable. 24,25 In a comprehensive review of the literature, including the vast majority of the aforementioned studies, 5,9-19,21-23, 25 Osborne et al concluded that the optimal dietary preparation would be ingestion of one or two high fat-no carbohydrate meals followed by a fast of at least 4 hours in duration (longer fasting does, however, seem to be associated with better results). 24 This practice had an 85% to 90% rate of efficacious glucose suppression in most of the studies.…”

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confidence: 99%

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

Andrikopoulou

Bhambhvani

2018

Journal of Nuclear Cardiology

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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.

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Impact of Patient Preparation on the Diagnostic Performance of 18F-FDG PET in Cardiac Sarcoidosis

Abstract: F-FDG PET/CT plays an integral role in the diagnosis of cardiac sarcoidosis. Diagnostic accuracy is affected by fasting duration and means of cardiomyocyte glucose uptake suppression before scanning.

Cited by 75 publications

References 28 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

A 1-week extension of a ketogenic diet provides a further decrease in myocardial 18F-FDG uptake and a high detectability of myocarditis with FDG-PET

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

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