ASNC Issues Official Endorsement of Cardiac PET as Preferred Imaging Modality for Suspected CAD

The American Society of Nuclear Cardiology (ASNC) has issued a landmark position statement declaring cardiac positron emission tomography (PET) the preferred imaging modality for evaluating patients with suspected coronary artery disease (CAD) who are candidates for myocardial perfusion imaging (MPI), if the technology is available. The recommendation, published in the Journal of Nuclear Cardiology, is the culmination of decades of clinical research and experience, and marks a major development in the field of nuclear cardiology.

The position statement, authored by a panel of experts that includes six former ASNC presidents, reflects the society’s continued efforts to promote the adoption of cardiac PET in clinical practice. It underscores the modality’s superior diagnostic accuracy, robust risk stratification capabilities, low radiation exposure, and expanding use across a variety of cardiovascular and systemic conditions. These include coronary microvascular disease, myocardial viability, cardiac sarcoidosis, cardiac amyloidosis, and infection.

“Based on the massive amount of clinical and scientific information now available and the latest U.S. and European guidelines, ASNC now recommends that PET MPI with myocardial blood flow, if available, should be the preferred modality for patients who meet criteria for MPI,” said Timothy Bateman, MD, lead author of the statement and a past president of ASNC. “There are no clinical scenarios or patient subgroups where cardiac PET with myocardial blood flow should be excluded.”

Since its introduction in the 1990s, cardiac PET has offered superior image quality compared to single photon emission computed tomography (SPECT), which has served as the primary imaging modality for cardiac perfusion since the 1970s. The integration of PET with CT attenuation correction has further improved accuracy, yet widespread adoption has been limited by equipment costs, access to radiotracers, and overall system availability.

While SPECT technology has seen gradual improvements, including digital detectors and AI-driven attenuation correction, PET has maintained a clear advantage, particularly due to its ability to quantify myocardial blood flow—a key tool in identifying microvascular disease. The new position statement outlines the specific clinical benefits of PET, including reproducibility, rapid exam times, enhanced diagnostic confidence, and the added anatomical information from the CT component. The option to perform coronary calcium scoring during the same exam further extends its clinical utility.

The statement also has important implications for payer policies and access to care. ASNC emphasized that previous guidance issued in 2016, which listed specific clinical scenarios where PET was preferable, no longer applies. The current guidance supports the use of PET for all patients requiring MPI, potentially removing insurance barriers that have historically required prior equivocal SPECT exams or specific patient characteristics such as high body mass index.

“In the past, insurers’ policies have too often denied cardiac PET testing unless patients met certain restrictive clinical characteristics,” said ASNC President Jamieson M. Bourque, MD, in a message to members. “That ends now. This statement confirms that all patients undergoing perfusion imaging are best served by cardiac PET with myocardial blood flow, if available. This is an important step toward ensuring patients have access to the best test.”

Insurers frequently consult clinical consensus statements when determining coverage policies, and ASNC expects this new recommendation to lead to expanded access to PET imaging. The group hopes the guidance will support broader investment in PET infrastructure and reduce prior authorization denials.

Cardiac PET is already experiencing rapid growth in adoption. Many nuclear labs had deferred equipment upgrades for years due to limited innovation. Following the COVID-19 pandemic, ASNC accelerated its efforts to encourage modernization, emphasizing the benefits of newer imaging platforms, especially PET-CT systems. Recent industry trends reflect this momentum, with increasing sales and prominent showcases of cardiac PET technology at major medical meetings, including the Radiological Society of North America (RSNA).

A major catalyst for PET expansion has been the U.S. Food and Drug Administration’s approval of the radiotracer flurpiridaz in September 2024. Unlike rubidium-82, which requires a costly generator system, flurpiridaz can be delivered in unit doses from regional radiopharmacies, making it a cost-effective option for outpatient centers with lower patient volumes. Experts have described its approval as a turning point for the field, with the potential to make cardiac PET more widely accessible than ever before.

With the new position statement, ASNC has made its stance clear: cardiac PET, when available, should be the standard of care for all patients undergoing myocardial perfusion imaging.