Diagnostic value of myocardial blood flow indices and perfusion assessment obtained during positron emission tomography with 13Nammonia combined with computer tomography and adenosine stress for detection multivessel coronary artery disease

Authors: Golukhova E.Z., Aslanidis I.P., Shurupova I.V., Shakhova A.A., Rumyantseva M.G., Ekaeva I.V., Trifonova T.A.

Company: Bakoulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russian Federation

For correspondence:  Sign in or register.

Type:  Original articles

DOI: https://doi.org/10.24022/1997-3187-2022-16-3-340-354

For citation: Golukhova E.Z., Aslanidis I.P., Shurupova I.V., Shakhova A.A., Rumyantseva M.G., Ekaeva I.V., Trifonova T.A. Diagnostic value of myocardial blood flow indices and perfusion assessment obtained during positron emission tomography with 13N-ammonia combined with computer tomography and adenosine stress for detectionmultivessel coronary artery disease. Creative Cardiology. 2022; 16 (3): 340–54 (in Russ.). DOI: 10.24022/1997-3187-2022-16-3-340-354

Received / Accepted:  20.02.2022 / 05.08.2022

Keywords: myocardial blood flow quantification coronary flow reserve positron emission tomography combined computed tomography 13N-ammonia myocardial perfusion

Full text:  



Objective. This study was to determine which parameters of stress-positron emission tomography (PET/CT) with 13N-ammonia contribute to an accurate identification of multivessel obstructive disease in patients with chronic coronary artery disease.

Material and methods. Study included 129 patients with 70% and more stenotic coronary lesions detected by angiography: 81 with single-vessel and 48 with multivessel disease. Stress-PET/CT-13N-ammonia dynamic scans were performed, global absolute and semiquantitative indices were obtained during rest and stress as well as relative perfusion images (presence of perfusion defect (PD) on a polar maps) and regional myocardial flow reserve (MFR) values were quantified.

Results. Comparison of all PET/CT derived semiquantitative indices revealed significant difference between two groups, as well as for myocardial blood flow (MBF) and for MFR (р < 0.05). The presence of multivessel disease (MVD) was defined: as PD in 2 or 3 related territories by visual analysis (sensitivity 38% and specificity 78%), and reduced MFR in 2 or 3 coronary territories according quantitative regional assessment (sensitivity and specificity were 85% and 60% respectively). ROC-analyses were performed and the optimal cut-off values for the detection of MVD for semiquantitative indices were: summed stress score (SSS) 10 and more with sensitivity and specificity 77% and 53% (AUC 0.703, p < 0.001), summed difference score (SDS) 8 (79% and 57% respectively, AUC 0.714, р < 0.001) and more; for absolute parameters – stress MBF 1.84 ml/min/g and less with sensitivity 60% and specificity 51% (AUC 0,668, р < 0.001); MFR 2.5 and less (81% and 58% respectively, AUC 0.775, р < 0.001).

Conclusion. Optimal criteria for the detection of significant MVD were: reduce of regional MFR in 2 or 3 coronary territories, optimal cut off for global values were SDS 8 and more and MFR 2.5 and less.


  1. Osnabrugge R.L., Head S.J., Bogers A.J., Kappetein A.P. Multivessel coronary artery disease: quantifying how recent trials should influence clinical practice. Expert Rev. Cardiovasc. Ther. 2013; 11 (7): 903–18. DOI: 10.1586/14779072.2013.811977
  2. Rozanski A., Gransar H., Hayes S.W., Min J., Friedman J.D., Thomson L.E. et al. Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009. J. Am. Coll. Cardiol. 2013; 61: 1054–65.
  3. Di Carli M.F. PET perfusion and flow assessment: tomorrows' technology today. Semin. Nucl. Med. 2020; 50 (3): 227–37. DOI: 10.1053/j.semnuclmed.2020.02.001 4. Cho S.G., Lee S.J., Na M.H., Choi Y.Y., Bom H.H. Comparison of diagnostic accuracy of PETderived myocardial blood flow parameters: a metaanalysis. J. Nucl. Cardiol. 2020; 27 (6): 1955–66. DOI: 10.1007/s12350-018-01476-z.
  4. Ryzhkova D.V., Kolesnichenko M.G., Boldueva S.A., Kostina I.S. The assessment of coronary haemodynamics in patients with саrdiac X syndrome using positron emission tomography. The Siberian Medical Journal. 2012; 27 (2): 50–6 (in Russ.).
  5. Boсkeria L.A., Aslanidis I.P., Shavman M.G., Shurupova I.V., Trifonova T.A., Ekaeva I.V. Diagnostic performance of quantitative 13N-ammonia positron emission tomography combined with computed tomography measures of myocardial blood flow and coronary flow reserve for the assessment of functional significance of coronary stenoses. Creative Cardiology. 2019; 13 (1): 17–27 (in Russ.). DOI: 10.24022/1997-3187-2019-13-1-17-27
  6. Boсkeria L.A., Aslanidis I.P., Mukhortova O.V., Shurupova I.V., Derevyanko E.P., Sil’chenkov A.V. et al. The advantages of clinical use of PET in cardiology, neurology and oncology. The Bulletin of Bakoulev Center. Cardiovascular Diseases. 2009; 10 (1): 12–26 (in Russ.).
  7. Dekemp R.A., Declerck J., Klein R., Pan X.B., Nakazato R., Tonge Ch. et al. Multisoftware reproducibility study of stress and rest myocardial blood flow assessed with 3D dynamic PET/CT and a 1-tissue-compartment model of 82Rb kinetics. J. Nucl. Med. 2013; 54: 571–7. DOI: 10.2967/jnumed.112.112219
  8. Boсkeria L.A., Aslanidis I.P., Shurupova I.V., Shavman M.G., Derevyanko E.P., Ekaeva I.V. et al. Quantitative noninvasive assessment of myocardial blood flow and coronary flow reserve using dynamic 13N-ammonia stress-PET/CT for the detection of the functional significance of coronary stenosis. The Bulletin of Bakoulev Center. Cardiovascular Diseases. 2017; 18 (5): 489–500 (in Russ.). DOI: 10.24022/1810-0694-2017-18-5-489-500
  9. Van Tosh A., Votaw J.R., Cook D.C., Cao J.J., Palestro C.J., Nichols K.J. Relationship of 82Rb PET territorial myocardial asynchrony to arterial stenosis. J. Nucl. Cardiol. 2020; 27 (2): 575–88. DOI: 10.1007/s12350-018-1350-4
  10. Gould K.L., Bui L., Kitkungvan D., Patel M.B. Reliability and reproducibility of absolute myocardial blood flow: does it depend on the PET/CT technology, the vasodilator, and/or the software? Curr. Cardiol. Rep. 2021; 23 (3): 12. DOI: 10.1007/s11886-021-01449-8
  11. Bockeriа L.A., Shurupova I.V., Aslanidis I.P., Chernova A.A., Trifonova T.A., Pursanova D.M. et al. Diagnostic possibilities of a one-stage evaluation of myocardial stress-perfusion and the degree of calcification of the coronary arteries with combined PET/CT studies. The Bulletin of Bakoulev Center. Cardiovascular Diseases. 2019; 20 (1): 33–45 (in Russ.). DOI: 10.24022/1810-0694-2019-20-1-33-45.
  12. Fiechter M., Ghadri J.R., Gebhard C., Fuchs T.A., Pazhenkottil A.P., Nkoulou R.N., et al. Diagnostic value of 13N-ammonia myocardial perfusion PET: added value of myocardial flow reserve. J. Nucl. Med. 2012; 53 (8): 1230–4. DOI: 10.2967/jnumed.111.101840
  13. Tanaka H., Chikamori T., Hida S., Igarashi Y., Shiba Ch., et al. Relationship of SYNTAX score to myocardial ischemia as assessed on myocardial perfusion. Circ. J. 2013; 77: 2772–7. DOI: 10.1253/circj.cj-13-0099
  14. Ziadi M.C., Dekemp R.A., Williams K., Guo A., Renaud J.M., Chow B.J. et al. Does quantification of myocardial flow reserve using rubidium-82 positron emission tomography facilitate detection of multivessel coronary artery disease? J. Nucl. Cardiol. 2012; 19 (4): 670–80. DOI: 10.1007/s12350-011-9506-5
  15. Naya M., Murthy V.L., Taqueti V.R. Foster C.R., Klein J., Garber M. et al. Preserved coronary flow reserved effectively excludes high-risk coronary artery disease on angiography. J. Nucl. Med. 2014; 55 (2): 248–55. DOI: 10.2967/jnumed.113.121442
  16. Joutsiniemi E., Saraste A., Pietilä M., Mäki M., Kajander S., Ukkonen H. et al. Absolute flow or myocardial flow reserve for the detection of significant coronary artery disease? Eur. Heart J. Cardiovasc. Imaging. 2014; 15 (6): 659–65. DOI: 10.1093/ehjci/jet274
  17. Schindler T.H., Facta A.D., Prior J.O., Cadenas J., Zhang X., Li Y. et al. Structural alterations of the coronary arterial wall are associated with myocardial flow heterogeneity in type 2 diabetes mellitus. Eur. J. Nucl. Med. Mol. Imaging. 2009; 36 (2): 219–29. DOI: 10.1007/s00259-008-0885-z. 19. Liu F.S., Wang S.Y., Shiau Y.C., Wu Y.W. Integration of quantitative absolute myocardial blood flow estimates from dynamic CZT-SPECT improves the detection of coronary artery disease. J. Nucl. Cardiol. 2022; 29 (5): 2311–21. DOI: 10.1007/s12350-021-02713-8

About Authors

  • Elena Z. Golukhova, Dr. Med. Sci., Professor, Academician of Russian Academy of Sciences, Director; ORCID
  • Irakliy P. Aslanidis, Dr. Med. Sci., Professor, Head of Department; ORCID
  • Irina V. Shurupova, Dr. Med. Sci., Leading Research Associate, Radiologist; ORCID
  • Margarita G. Rumyantseva, Сand. Med. Sci., Senior Research Associate, Radiologist; ORCID
  • Anzhelika A. Shakhova, Postgraduate; ORCID
  • Irina V. Ekaeva, Сand. Chem. Sci., Leading Research Associate; ORCID
  • Tat’yana A. Trifonova, Cand. Med. Sci., Head of Department; ORCID

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery