Comparative diagnostic performance of [18F] flurpiridaz PET and SPECT myocardial perfusion imaging (MPI): a systematic review and meta-analysis.

This study aimed to synthesise diagnostic evidence comparing a novel myocardial perfusion radiotracer [¹⁸F]flurpiridaz PET with SPECT myocardial perfusion imaging (MPI) in detecting coronary artery disease (CAD). A systematic search to Feb 2026 was conducted in Web of Science, Scopus, PubMed, and the Cochrane Library. Studies comparing [¹⁸F]flurpiridaz PET with SPECT/MPI were screened. Primary outcomes were sensitivity and specificity using invasive coronary angiography as the reference standard. Secondary outcomes included image quality and radiation dose. Out of 558 studies, 28 publications were fully screened, and three trials comparing [¹⁸F]flurpiridaz PET with [⁹⁹ᵐTc]Tc-sestamibi/tetrofosmin SPECT were identified (1476 patients). For ≥ 50% stenosis, pooled sensitivity/specificity were 76% (95% CI 71-81%)/71% (63-78%) for flurpiridaz PET and 61% (53-69%)/76% (60-86%) for SPECT; for ≥ 70% stenosis, values were 87% (77-94%)/63% (52-73%) versus 73% (62-81%)/72% (50-87%), respectively. In patients with BMI ≥30kg/m², sensitivity/specificity were 74% (68-78%)/73% (64-80%) for flurpiridaz PET and 61% (49-72%)/75% (56-88%) for SPECT. In women, sensitivity/specificity were 73% (57-84%)/76% (70-81%) for flurpiridaz PET versus 50% (29-70%)/78% (60-90%) for SPECT. Rest and stress image quality favoured flurpiridaz PET (RR1.29[1.19-1.41] and 1.14[1.11-1.17], both p<0.00001) with superior image quality and lower radiation dose. This first meta-analysis suggests higher sensitivity of [¹⁸F]flurpiridaz PET vs SPECT MPI with significantly lower radiation dose and improved image quality. [¹⁸F]flurpiridaz is especially useful for assessing women and patients with high BMI, given its superior sensitivity and comparable subgroup specificity. However, findings should be interpreted cautiously due to the limited number of studies.