My name is Tim Bateman. I have with me here today Dr. Gary Heller, and we are going to be talking with Dr. Muaz Elmela, who is president currently of American Society of Nuclear Cardiology. Dr. Elmela, you have a great global perspective about what's going on in the world of nuclear cardiology. Now, I've heard that something like 92% of all of PET scans that are done worldwide are done in the United States. What are your thoughts about this new tracer and how it might expand PET utilization across the world? First, thanks for having me. And yeah, you're right, I mean, PET, specifically cardiac PET, is mostly done in the United States. Unfortunately, our patients outside the United States don't have access to these important modalities. And there are some big countries where there is zero cardiac PET happening, even some advanced countries in Europe and around the globe. I think there are multiple reasons for that. Part of it is reimbursement, but also part of it is some sites don't have the high volume that they needed to justify getting a generator or a cyclotron. So I think with a unit dose-based tracer, I think that will allow many sites, many countries, and many sites that have PET scan installed, but they need a tracer, a unit dose tracer, to do few cases on some days of the week to allow them to do cardiac PET and offer it to some patients who are not best served by other modalities that are currently available. That include the obese patients, that include identification of CMD and microvascular dysfunction, that includes many other patients that currently are struggling. Like for example, there are many countries that do transplants and they don't have PET there and they need it to follow up for coronary allograft vasculopathy and others. So I think this is going to be a big breakthrough that allows some low volume sites that have PET scans to initiate cardiac PET service and bring it to their patients. So we've been talking about the transitions from SPECT to PET, and even in our own country, the educational connotations of something like that is significant. In some of these countries that have not had any exposure to PET or any training, I imagine that they are going to need a lot of hand-holding. You're absolutely right. I think training is going to be a key really to successfully launch this tracer, not only for the newer sites, but even for the existing sites who have not used an F18-based perfusion agent. Images look different. You have higher uptake, so you might see my smaller non-obstructive defects, non-obstructive disease-causing defects. But also, some sites who have not done any cardiac PET, and they're going to do it even at the lower volume, I think they need a lot of support to learn PET, to learn about my cardioblood flow assessment with this agent, but also how to educate the referring physicians, how to educate them, how to put their report, integrate the data all together, because we want to make sure that we want to have good specificity as well as good sensitivity, and we want to send the appropriate patients to the cath lab. So I think the key to successfully launch this agent is really relies on good education, good training to everybody, but specifically more so focus on the lower volume sites. So what you're talking about are countries that currently are doing PET oncology that now could expand to cardiac PET because it's another F18 agent. So I'm assuming the cyclotrons are there, so it's a matter of production and getting people trained to do it. I think, like, this year I visited many countries, like, for example, Brazil, 220 million citizens, but still zero cardiac PET. They have 150 PET scans installed. They have almost 15 or so cyclotrons. So I think at least if we manage to get some studies done in some sites with some cities that are 20 million or so, I think that's going to be a big advantage. There are many countries in Europe that have PET scans, have cyclotrons, but they are not able to do myocardial perfusion imaging. And there are, so PET install base have significantly increased due to oncological applications. I think with an F18 perfusion agent, that will allow some of these countries to add some cardiac cases if the tracer is available. I think availability of the tracer is going to be an important discussion point that should make it, like, more accessible to make this tracer more accessible to patients. And what about home? Do you think we're ready for an F18 perfusion agent? I think, like, even during the trial, there were some challenges with that. I think globally, like, to be able to cover the entire country, I think probably it will start from bigger cities and then expand it out. In the U.S., there are, like, estimates between 2,800 to 3,000 PET machines installed. I think if you look at hospitals, only 100 hospitals, almost 100 hospitals built Medicare last year for PET perfusion. So you can think that there are almost 2,900 PET scanners are not doing any cardiac scan. If we get half of them to do a few cases, I think that are in big cities where distribution or production of this agent is easy. You can see the amount of benefit that these patients will get from access to such a procedure when they need it the most. So late breaking news, as you know, the ACC has come out with some new guidelines about the assessment and treatment of chronic coronary disease, and it has emphasized the value of PET over SPECT. And that's a first, right? And I just wondered if you had any one-sentence thoughts about guidance to cardiologists in America about what that means? It's not only PET over SPECT. I think PET is the go-to modality for many patients. Actually it's the only option that's available for some patients. And some patients, you may have options. So if there are multiple options, then I would say PET is preferred over SPECT. But I see in my practice many patients where PET is the only realistic modality. Take for example a patient with morbid obesity, like BMI of 45 or so. You're not going to get a good, adequate image quality with multiple other modalities. So I think PET may be the only reliable option in some patients. And in some patients where you have other options, PET is going to be the... And especially for those patients with chronic coronary disease who already have coronary disease, perhaps have been revascularized. And also CMD diagnosis. In the guidelines, only quantitative PET and quantitative CMR are the only modalities. But quantitative PET is, at least in this country, more available compared to other modalities. So I think CMD is not a minor thing. I mean, we know from the schema trial that it is prevalent and it is there. And we heard many presentations in this conference about that. So that's a very important part, and that's a very important aspect of PET. And yet a lot of the guidelines recommend doing exercise first if you can do exercise. Do you agree with that? It seems like blood flow contributes so much. How do we work through that? So I think from a PET standard, because currently, with the current research, we cannot do exercise. My approach to this is that if you want exercise data, you can get a treadmill and then potentially get the blood flow. To me, the biggest advantage of PET, in addition to many advantages, but if I want to pick up just one, that's going to be my cardio-blood flow assessment. So I don't want to sacrifice that. So I can get exercise data from other ways and then look at the blood flow data. So we should develop protocols for this trace and other that does not sacrifice blood flow assessment. Yeah, that's a great point. If we want to know something about the relationship between symptoms and exercise, we can do just a plain old exercise test. Well, very good. This is an excellent discussion and I appreciate your perspective about what you think this new agent is going to, how it's going to affect the marketplace in the U.S. and worldwide. Well, thanks for having me. Thank you.

Dr. Muaz Elmela

new tracer

cardiac PET scans

global impact

accessibility