Cardiac PET imaging for the detection and monitoring of coronary artery disease and microvascular health

This review makes an argument that conventional imaging often misses: that the health of the heart’s small vessels matters, and PET can measure it.

The key capability is quantifying myocardial blood flow and flow reserve — how much the heart can increase its own blood supply under demand. The authors show that PET-measured flow reserve detects coronary vascular dysfunction early, including the microvascular disease that exists even without an obvious blockage, and that it carries prognostic weight beyond anatomy: a poor flow reserve predicts risk regardless of whether a major artery is narrowed.

The practical takeaway is that PET flow quantification can surface and monitor a layer of disease — microvascular dysfunction — invisible to tests that look only for obstruction, and could guide therapy if used more widely. The resistance is reimbursement and practice patterns built around angiography and standard stress testing.

We rate the evidence moderate: an authoritative synthesis from leading PET researchers, conflict-free, but a review without original data. Its clinical significance is moderate-to-high in concept — microvascular health is an underappreciated axis of cardiac risk — though, like other PET reviews here, real-world adoption stays limited by access and cost.