New Promising Targets for Imaging in Cardiovascular Diseases.

Abstract

Cardiovascular diseases (CVDs) remain the leading cause of morbidity and mortality worldwide, driven by complex and dynamic molecular processes such as inflammation, fibrosis, metabolic dysregulation, thrombosis, and vascular remodeling. While conventional imaging techniques provide valuable anatomical and functional information, they fail to capture these underlying pathophysiological mechanisms at the molecular level. Molecular imaging, particularly with PET and SPECT, offers the potential to noninvasively visualize and quantify these processes, enabling earlier diagnosis, better risk stratification, and more precise treatment guidance. Despite substantial progress in clinical cardiology, there is a growing need for novel radiotracers that can target key disease-driving mechanisms beyond traditional perfusion or viability imaging. Emerging radiopharmaceuticals now enable the assessment of myocardial fibrosis (e.g., collagen-targeted and MMP-targeted tracers), cardiomyocyte stress responses (e.g., oxidative stress, unfolded protein response, endothelin signaling), and metabolic alterations (e.g., fatty acid, ketone, and glucose metabolism). Additionally, new tracers are being developed for thrombosis, vascular inflammation, plaque instability, and even for innovative targets such as cellular senescence and gut-derived inflammatory pathways. These developments reflect a paradigm shift towards imaging-driven phenotyping of cardiovascular disease. This review provides a comprehensive overview of the latest advances in molecular imaging tracers for cardiovascular applications, with a focus on their biological rationale, preclinical and clinical evidence, and translational challenges. We categorize tracers by their mechanistic targets and highlight their potential for integration into precision cardiology.