Advances in nuclear hybrid imaging: The role of SPECT/CT, PET/CT, and PET/MRI in cardiovascular diseases

Hybrid imaging has transformed nuclear cardiology by integrating anatomical and molecular data. Positron emission tomography (PET) /CT and single-photon emission computed tomography (SPECT)/CT improve diagnostic accuracy through attenuation correction, coronary artery calcium (CAC) scoring, and precise localization of tracer uptake. These advances enhance risk stratification, differentiate obstructive from microvascular disease, and detect extracardiac pathology. Despite these strengths, adoption remains limited. Misregistration, motion artifacts, and suboptimal CT quality restrict image reliability, while reimbursement gaps, workforce shortages, and training standards may hinder broader adoption. The frequent detection of incidental findings further underscores the need for structured reporting protocols, yet reimbursement pathways remain unclear. PET/magnetic resonance imaging (MRI) offers unique advantages by combining the molecular sensitivity of PET with the superior soft tissue characterization of MRI, without additional radiation. This modality is particularly valuable in myocarditis, sarcoidosis, viability assessment, and cardiac tumors, where multiparametric data refine diagnosis and guide management. Motion correction using real-time MRI tracking adds further potential. However, PET/MRI adoption is constrained by high costs, technical complexity, prolonged scan times, and limited validation outside tertiary centers. The lack of large multicenter outcome studies continues to restrict its role to research settings, where its strengths in tissue characterization and integrated functional assessment are most apparent.