New Guidelines Aim to Optimize PET Imaging in Coronary Artery Disease

Coronary artery disease (CAD) remains the leading cause of death globally, placing a major burden on health systems and diminishing quality of life for millions of patients. As advanced imaging continues to play a critical role in diagnosing and managing the condition, new guidelines are offering clinicians a roadmap for avoiding common errors when using PET imaging in this setting.

Developed jointly by the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and partner organizations including the American Society of Nuclear Cardiology, the recommendations center on how to maximize the value of PET, particularly when using novel radiotracers that have shown improved diagnostic performance compared to conventional approaches. Clinical evidence has already highlighted that these tracers provide clearer images, more accurate assessments, and greater sensitivity in detecting clinically significant coronary artery stenosis.

The new consensus document emphasizes three main areas: selecting the right patients, applying proper imaging protocols, and carefully interpreting the results. Alongside these broader themes, the authors outline seven pitfalls that clinicians should work to avoid in order to ensure accurate and clinically useful scans.

One of the most fundamental recommendations is the importance of rigorous quality control. The authors note that many artifacts encountered in PET/CT scans are preventable, often arising from issues with patient cooperation, processing techniques, or technical limitations of the imaging system. Ensuring appropriate calibration and review of raw data is therefore considered critical to reliable outcomes.

The guidelines also highlight technical challenges posed by metallic implants such as pacemakers. These can produce streaks or distortions in CT transmission images, which in turn can compromise fused PET/CT results. Careful review and corrective strategies are necessary to minimize their impact on scan interpretation.

Another key focus is patient positioning. Stable and comfortable positioning reduces the risk of motion artifacts, which can obscure perfusion defects or lead to inaccurate myocardial blood flow (MBF) calculations. Related to this, the authors stress the need for proper registration between CT and PET datasets. Misalignment can mimic or mask disease by creating artifactual perfusion defects, particularly in the anterior and lateral myocardial walls.

Accurate quantification of MBF is another recurring theme. The guidelines recommend validating myocardial and blood pool regions and applying motion correction when needed to avoid misleading flow estimates. In same-day protocols, clinicians are advised to correct for residual radiotracer activity between rest and stress studies, as failing to do so can lead to overestimation of flow reserve.

Finally, the use of automated motion correction software is strongly encouraged. Many commercial platforms already incorporate these tools, and the authors note they are especially important when working with radiotracers such as 18F-flurpiridaz.

Taken together, the guidelines underscore that while PET offers superior diagnostic performance in CAD imaging, attention to detail in acquisition and analysis is vital. By standardizing best practices and highlighting common pitfalls, the collaborating societies hope to improve diagnostic accuracy and ensure that patients benefit fully from the technology.

The full guidance document was published September 18 in the Journal of Nuclear Medicine.