Central Illustration. 18F-sodium fluoride positron emission tomography as a marker of disease activity in the coronary arteries is a predictor of fatal or non-fatal myocardial infarction (MI) in patients with established coronary artery disease.
18F-fluoride PET can be used to measure disease activity across the coronary vasculature and to stratify patients into those with no, low and high disease activity. Patients with high disease activity (coronary microcalcification activity (CMA) >1.56) demonstrate a >7-fold risk of myocardial infarction. These patients might therefore be suitable for advanced medical therapies including PCSK9 or interleukin 1-beta inhibition, with 18F-fluoride PET used for targeting these expensive drugs to patients at greatest risk. Patients without coronary 18F-NaF uptake (CMA=0) have an excellent prognosis with no myocardial infarctions observed during follow-up despite advanced coronary artery disease. In these patients with dormant coronary artery disease (a third of the population studied), further intensification of medical therapy might not be warranted, nor might they benefit on prognostic grounds from complex revascularization such as multivessel percutaneous intervention or coronary artery bypass grafting.