Cardiac PET in the Last Five Years: Established Tracers, Novel Radiopharmaceuticals, and Translational Challenges

Cardiac positron emission tomography (PET) has undergone substantial development in recent years, moving beyond conventional perfusion imaging toward a multiparametric and increasingly quantitative assessment of cardiovascular disease. This article provides a critical narrative overview of the recent cardiac PET literature, with particular emphasis on studies published over the last five years, and discusses both established tracers and emerging radiopharmaceuticals in contemporary cardiology. Among established applications, 18F-FDG remains relevant for myocardial viability assessment and selected inflammatory indications, although its prognostic and therapeutic implications are less uniform than earlier narratives suggested. For myocardial perfusion imaging, 13N-ammonia and 82Rb PET provide robust assessment of myocardial blood flow and myocardial flow reserve, but their clinical interpretation remains strongly influenced by acquisition protocols, software reproducibility, and methodological standardization. The review also addresses newer tracers, including 68Ga-FAPI for fibroblast activation, 18F-flurpiridaz for high-performance perfusion imaging, 18F-FDOPA for cardiac sympathetic dysfunction, and amyloid-binding PET radiopharmaceuticals for cardiac amyloidosis. Overall, recent evidence supports cardiac PET as a powerful platform for physiologic and molecular imaging, but not as a uniform or methodologically neutral technology. Its current value lies in selective, question-driven clinical use, whereas broader implementation will depend on tracer-specific validation, harmonized quantitative workflows, and clear demonstration of incremental benefit over existing imaging strategies.