Clinical value of a high-fat and low-carbohydrate diet before FDG-PET/CT for evaluation of patients with suspected cardiac sarcoidosis

doi:10.1007/s12350-012-9653-3

Journal of Nuclear Cardiology

Volume 20, Issue 1, February 2013, Pages 120-127

https://doi.org/10.1007/s12350-012-9653-3 Get rights and content

Abstract

Background

We hypothesized that a high-fat and low-carbohydrate (HFLC) diet before FDG-PET/CT could identify patients with active cardiac sarcoidosis (CS).

Methods

Fifty-eight sarcoidosis patients with a suspicion of CS consumed a HFLC diet before FDG-PET/CT. Clinical, electrical, and other imaging investigations were compared to PET results.

Results

Using Japanese Ministry of Health and Welfare (JMHW) criteria as a gold standard, 21% (12/58) of patients had a CS. Sensitivity and specificity of PET (visual analysis) were 83% (10/12) and 78% (36/46), respectively, with a very good interobserver agreement (k = 0.86). 70% (7/10) of the patients with a positive PET and negative JMHW criteria exhibited abnormalities suggestive of CS either on MR (n = 3) or SPECT (n = 4). Comparison with the presence of delayed enhancement on magnetic resonance imaging helped to classify patients with active (PET positive) or non-active CS (PET negative). In addition, when MR and PET were both negative, none of the patients met the JMHW criteria. PET response under treatment was concordant with clinical evolution in 11/13 patients.

Conclusions

FDG-PET/CT after HFLC diet is a sensitive tool for the diagnosis of active CS. Combined use of PET and MR is promising for the detection and characterization of CS lesions.

Introduction

Cardiac involvement in sarcoidosis is a cause of morbidity and mortality, from conduction abnormalities to arrhythmias and/or congestive heart failure. The diagnosis of cardiac sarcoidosis (CS) is critical since medical treatment, mainly steroids and implantable devices, improved considerably the disease prognosis.¹^,² However, diagnosing the disease remains one of the most challenging issues in sarcoidosis. The diagnosis is usually made by integrating clinical and imaging data and no gold standard is universally admitted. The criteria proposed by the Japanese Ministry of Health and Welfare (JMHW), revised in 2006, are very useful in clinical practice and have been frequently used as the clinical gold standard for the diagnosis of CS.³

The usefulness of Positron emission tomography/computed tomography with fluorodeoxyglucose (FDG-PET/CT) for the diagnosis of CS has been poorly investigated.⁴^,⁵ One major challenge in using FDG-PET/CT is the unpredictable physiological uptake of cardiac muscle, which may interfere with the detection of cardiac active granulomatous disease.⁶ Methodology and interpretation methods of previous studies are heterogeneous. Authors used either fasting and/or pre-administration of unfractioned heparin to suppress physiological uptake. Data showed discrepancies in sensitivity and specificity7, 8, 9, 10, 11 Recently, a regimen based on high-fat and low-carbohydrate diet (HFLC) before FDG injection has been used to suppress physiological myocardial FDG uptake.¹²^,¹³ Its principle is based on the Randle cycle, a metabolic process involving the competition of glucose and fatty acids for substrates in myocardial cells.¹²^,¹⁴^,¹⁵ To the best of our knowledge, the impact of the HFLC diet has not been applied on a large series of sarcoidosis patients.¹⁶ We hypothesized that the HFLC diet before FDG-PET/CT could identify patients with active CS.

Section snippets

Sarcoidosis patients

This study was approved by the ethical committee of Ile-de-France X (No. 2010-12-01). From February 2009 to August 2011, 65 consecutive biopsy-proven sarcoidosis patients with a suspicion of CS underwent a FDG-PET/CT after a HFLC diet in this retrospective study. Patients had been recruited from the pulmonary department of Avicenne university hospital, a tertiary reference center for sarcoidosis in France. These patients had no prior myocardial infarction or known coronary disease. x-ray

Controls

Results of visual assessment are described in Table 2. Controls exhibited the none pattern in 77% (23/30). None of the controls exhibited the “focal on diffuse” pattern. Five patients exhibited the “focal” pattern (5/30, 15%), located in all cases in the papillary muscle. Quantitative analysis showed a median value of 2.25 (range: 1.3-12) for SUVmax and 1.2 (range 0.8-5.7) for SUVmax/SUVbp. The highest SUVmax values (12 and 4.2) were related to the presence of the “diffuse” pattern.

Sarcoidosis patients

The

Discussion

Diagnosing CS is a medical challenge. Although FDG-PET/CT has gained wide acceptance,⁴^,⁵ unpredictable physiological FDG uptake by normal myocardium considerably hampers image interpretation. The HFLC diet used in this study has never been evaluated in a case-control study of sarcoidosis patients to our knowledge. We showed that a HFLC diet before FDG-PET/CT eliminates efficiently the myocardial physiological uptake, except in the papillary muscle (15% of controls). Thus, the visual analysis of

Conflict of interest

The authors declare no conflict of interest.

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Original ArticleClinical value of a high-fat and low-carbohydrate diet before FDG-PET/CT for evaluation of patients with suspected cardiac sarcoidosis

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Sarcoidosis patients

Controls

Sarcoidosis patients

Discussion

Conflict of interest

Am Heart J

J Nucl Cardiol

J Nucl Cardiol

Lancet

J Nucl Cardiol

JACC Cardiovasc Imaging

J Am Coll Cardiol

Chest

Am J Med

Cardiac sarcoidosis

Rev Mal Respir

Jpn J Sarcoidosis Granulomatous Disord

(18)F-Fluoro-2-deoxyglucose positron emission tomography in cardiac sarcoidosis

Eur J Nucl Med Mol Imaging

Detecting cardiac involvement in sarcoidosis: A call for prospective studies of newer imaging techniques

Eur Respir J

Evaluation of the relationship between physiological FDG uptake in the heart and age, blood glucose level, fasting period, and hospitalization

Ann Nucl Med

Focal uptake on 18F-fluoro-2-deoxyglucose positron emission tomography images indicates cardiac involvement of sarcoidosis

Eur Heart J

Myocardial imaging with 18F-fluoro-2-deoxyglucose positron emission tomography and magnetic resonance imaging in sarcoidosis

Eur J Nucl Med Mol Imaging

Original Article
Clinical value of a high-fat and low-carbohydrate diet before FDG-PET/CT for evaluation of patients with suspected cardiac sarcoidosis