Evaluation of Myocardial Blood Flow Using 18F-flurpiridaz PET: Established Applications with Pharmacologic Stress and Roadmap for Exercise Stress Implementation

Q: What are the key findings of this study?

18F-flurpiridaz PET enables validated pharmacologic stress myocardial blood flow quantitation (<1.6-1.7 mL/min/g indicating CAD) and has a 110-min half-life supporting exercise-stress imaging.

Q: What is the clinical evidence from this study?

Study design: Review. Population: Known or suspected coronary artery disease (CAD). Intervention: 18F-flurpiridaz PET myocardial perfusion imaging (pharmacologic and exercise stress).

Q: What does this research mean for the field?

18F-flurpiridaz PET provides validated myocardial blood flow quantitation during pharmacologic stress, and its 110-minute half-life creates viable but technically challenging pathways for exercise-stress flow quantification. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Farzana Ali; Piotr J. Slomka; René R. Sevag Packard

doi:10.1007/s11886-026-02439-4

October 23, 2026Current Cardiology ReportsOpen Access

Evaluation of Myocardial Blood Flow Using 18F-flurpiridaz PET: Established Applications with Pharmacologic Stress and Roadmap for Exercise Stress Implementation

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Key result

18F-flurpiridaz PET enables absolute myocardial blood flow quantitation and supports exercise-stress imaging.

Why the study?

The recently approved 18F-flurpiridaz tracer expands access to quantitative cardiac PET myocardial blood flow assessment, prompting evaluation of its established pharmacologic stress applications and potential implementation with exercise stress.

Does 18F-flurpiridaz PET under pharmacologic or exercise stress enable accurate quantitation of myocardial blood flow and myocardial flow reserve in adults with known or suspected coronary artery disease?

Key Points

To review established applications of 18F-flurpiridaz PET for measuring myocardial blood flow during pharmacologic stress and outline emerging strategies for exercise stress implementation.
Review of clinical and preclinical evidence evaluating 18F-flurpiridaz (approximate half-life of 110 min) for positron emission tomography myocardial perfusion imaging.
Evaluation of analytical pathways for exercise stress blood flow quantitation, including machine learning-derived virtual metrics, standardized uptake value ratio calibrations, and dynamic kinetic modeling during in-scanner ergometry.
Absolute myocardial blood flow and myocardial flow reserve provide incremental diagnostic value over relative perfusion imaging during pharmacologic stress across multiple software platforms.
In preclinical pig models, 18F-flurpiridaz standardized uptake values measured 5 to 12 min post-injection correlated strongly with microsphere reference flow (r=0.92, p<0.001).
Feasibility studies in 220 patients undergoing pharmacologic or treadmill testing demonstrated that standardized uptake value ratio-derived flow reserve can detect multivessel disease after adjusting for a 2.2 uptake ratio difference between stress modalities.

Structured PICO

Does 18F-flurpiridaz PET under pharmacologic or exercise stress enable accurate quantitation of myocardial blood flow and myocardial flow reserve in adults with known or suspected coronary artery disease?

P

Population

Adults with known or suspected coronary artery disease undergoing myocardial perfusion imaging

I

Intervention

18F-flurpiridaz positron emission tomography (PET) myocardial perfusion imaging under pharmacologic stress or exercise stress (including investigational pathways: AI/ML virtual flow prediction, static-image standardized uptake value ratio [SUVR] calibration, and dynamic time-activity curve modeling during in-scanner ergometry)

C

Comparator

Relative perfusion imaging, invasive coronary angiography, or other PET tracers (such as 82Rb-chloride, 13N-ammonia, 15O-water)

O

Outcome

Quantitation and estimation of absolute myocardial blood flow (MBF) and myocardial flow reserve (MFR) for the detection of coronary artery diseasesurrogate

18F-flurpiridaz is an FDA-approved PET tracer with a 110-minute half-life that provides validated pharmacologic stress myocardial blood flow quantitation and enables novel investigational pathways for assessing flow during physiologic exercise stress.

Limitations

No animal or human subjects were directly evaluated in this narrative review.
Hyperemic MBF and MFR thresholds for 18F-flurpiridaz have not been prospectively validated.
Early tracer kinetics cannot be captured during standard out-of-scanner exercise stress, precluding conventional MBF assessment.
Sufficiently large datasets are not yet available to develop robust multimodal AI models for 18F-flurpiridaz.
Semi-quantitative SUV and SUVR metrics do not directly measure MBF and are sensitive to technical and physiologic factors.
Lack of standardized reference ranges and quality control frameworks for exercise-stress MBF estimation.
In-scanner exercise PET MBF quantitation faces technical challenges related to patient motion, specialized ergometer requirements, and kinetic modeling.
Early tracer kinetics cannot be captured during conventional out-of-scanner exercise stress, precluding standard first-pass MBF quantitation
Sufficiently large datasets are not yet available to develop robust multimodal AI models for 18F-flurpiridaz
Standardized uptake value (SUV) does not directly measure MBF and is sensitive to technical and physiologic factors including reconstruction parameters, motion, scanner calibration, uptake time, and body composition
Exercise stress protocols lack standardized reference ranges and quality control frameworks for MBF estimation
In-scanner exercise PET is limited by patient motion, need for specialized ergometers, sustained exercise within the scanner bore, and requirement for novel kinetic modeling

Implication

Supports pharmacologic stress MBF quantitation now; leaves exercise-stress applications open for pragmatic validation.

Abstract

Purpose of Review Recently approved by the United States Food and Drug Administration, 18 F-flurpiridaz for positron emission tomography (PET) myocardial perfusion imaging (MPI) enables high-quality assessment of myocardial blood flow (MBF). Its half-life of approximately 110 min supports regional distribution and allows unit-dose delivery. These features make this probe well suited for MBF quantitation and expand access to quantitative cardiac PET at smaller centers. Recent Findings During pharmacologic stress, absolute MBF and myocardial flow reserve provide incremental diagnostic information beyond relative perfusion imaging. These measures have been validated across multiple methods and software platforms. Further study of this tracer under peak exercise may provide clinically relevant assessment of myocardial demand-induced changes in flow. Potential investigational approaches include artificial intelligence (AI)-derived virtual MBF, exercise-adjusted standardized uptake value (SUV) ratio-derived myocardial flow reserve (MFR) surrogate, and direct kinetic modeling during in-scanner ergometry. Summary While conceptually promising, limitations inherent to exercise-based approaches in stress MBF and/or MFR estimation highlight the need for pragmatic research strategies before potential clinical applicability.

Discussion

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Cite This Study

Ali et al. (2026) conducted a review in Known or suspected coronary artery disease (CAD). 18F-flurpiridaz PET myocardial perfusion imaging (pharmacologic and exercise stress) was evaluated. 18F-flurpiridaz PET enables validated pharmacologic stress myocardial blood flow quantitation (<1.6-1.7 mL/min/g indicating CAD) and has a 110-min half-life supporting exercise-stress imaging.

synapsesocial.com/papers/6adc966ca704d151585a5e69 https://doi.org/10.1007/s11886-026-02439-4

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Evaluation of Myocardial Blood Flow Using 18F-flurpiridaz PET: Established Applications with Pharmacologic Stress and Roadmap for Exercise Stress Implementation

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Evaluation of Myocardial Blood Flow Using 18F-flurpiridaz PET: Established Applications with Pharmacologic Stress and Roadmap for Exercise Stress Implementation

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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