Purpose

Inflamed, prone-to-rupture coronary plaques are an important cause of myocardial infarction and their early identification is crucial. Atherosclerotic plaques are characterized by overexpression of the type-2 somatostatin receptor (SST₂) in activated macrophages. SST₂ ligand imaging (e.g. with [⁶⁸ Ga]Ga-DOTA-TOC) has shown promise in detecting and quantifying the inflammatory activity within atherosclerotic plaques. However, the sensitivity of standard axial field of view (SAFOV) PET scanners may be suboptimal for imaging coronary arteries. Long-axial field of view (LAFOV) PET/CT scanners may help overcome this limitation. We aim to assess the ability of [⁶⁸ Ga]Ga-DOTA-TOC LAFOV-PET/CT in detecting calcified, SST₂ overexpressing coronary artery plaques.

Methods

In this retrospective study, 108 oncological patients underwent [⁶⁸ Ga]Ga-DOTA-TOC PET/CT on a LAFOV system. [⁶⁸ Ga]Ga-DOTA-TOC uptake and calcifications in the coronary arteries were evaluated visually and semi-quantitatively. Data on patients' cardiac risk factors and coronary artery calcium score were also collected. Patients were followed up for 21.5 ± 3.4 months.

Results

A total of 66 patients (61.1%) presented with calcified coronary artery plaques. Of these, 32 patients had increased [⁶⁸ Ga]Ga-DOTA-TOC uptake in at least one coronary vessel (TBR: 1.65 ± 0.53). Patients with single-vessel calcifications showed statistically significantly lower uptake (SUV_max 1.10 ± 0.28) compared to patients with two- (SUV_max 1.31 ± 0.29, p < 0.01) or three-vessel calcifications (SUV_max 1.24 ± 0.33, p < 0.01). There was a correlation between coronary artery calcium score (CACS) and [⁶⁸ Ga]Ga-DOTA-TOC uptake, especially in the LAD (p = 0.02). Stroke and all-cause death occurred more frequently in patients with increased [⁶⁸ Ga]Ga-DOTA-TOC uptake (15.63% vs. 0%; p:0.001 and 21.88% vs. 6.58%; p: 0.04, respectively) during the follow-up period.

Conclusion

[⁶⁸ Ga]Ga-DOTA-TOC as a marker for the macrophage activity can reveal unknown cases of inflamed calcified coronary artery plaques using a LAFOV PET system. [⁶⁸ Ga]Ga-DOTA-TOC uptake increased with the degree of calcification and correlated with higher risk of stroke and all-cause death. [⁶⁸ Ga]Ga-DOTA-TOC LAFOV PET/CT may be useful to assess patients' cardiovascular risk.