{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T06:30:13Z","timestamp":1792132213345,"version":"4.4.0"},"reference-count":39,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"4","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Cardiovascular Imaging"],"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND:<\/jats:title>\n                    <jats:p>\n                      Myocardial flow reserve (MFR), measured by positron emission tomography (PET) myocardial perfusion imaging, provides valuable information on epicardial coronary disease, diffuse atherosclerosis, and microvascular function. Despite its routine use, the prognostic efficacy of\n                      <jats:sup>13<\/jats:sup>\n                      N-ammonia PET MFR remains unconfirmed in larger multicenter cohorts of patients with suspected or known coronary artery disease.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS:<\/jats:title>\n                    <jats:p>\n                      We considered patients from 5 sites in the REFINE PET (Registry of Flow and Perfusion Imaging for Artificial Intelligence with PET) registry who underwent\n                      <jats:sup>13<\/jats:sup>\n                      N-ammonia PET myocardial perfusion imaging for coronary artery disease. Clinical and imaging data were collected at the time of myocardial perfusion imaging. MFR was quantified as the ratio of stress to rest myocardial blood flow, using QPET software (Cedars-Sinai Medical Center, Los Angeles, CA). The primary outcome was all-cause mortality. Survival analyses were performed using Kaplan-Meier and Cox regression models adjusted for clinical and imaging covariates.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS:<\/jats:title>\n                    <jats:p>\n                      In total, 6277 patients were included (median age of 65 years, 56% male). Median follow-up time was 3.8 years. There were 1895 patients with MFR \u22642 and 4382 with MFR &gt;2. Patients with MFR \u22642 had significantly higher mortality than those with MFR &gt;2 (n=701 [37.0%] versus n=537 [12.3%], respectively;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;0.001). Annualized all-cause mortality rates by MFR and summed stress score ranged from 1.7 to 15.8. In multivariable analysis, MFR \u22642 was independently associated with increased all-cause mortality in the overall population (hazard ratio, 2.70 [95% CI, 2.41\u20133.03];\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;0.001), even among patients with no perfusion defects (hazard ratio, 2.36 [95% CI, 1.93\u20132.89];\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;0.001). Mortality risk decreased across increasing MFR deciles, ranging from hazard ratio, 2.73 (95% CI, 2.39\u20133.11) to hazard ratio, 0.35 (95% CI, 0.25\u20130.49).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>\n                      In this large multicenter cohort, MFR derived from\n                      <jats:sup>13<\/jats:sup>\n                      N-ammonia PET myocardial perfusion imaging is a strong, independent predictor of all-cause mortality, even in patients with normal perfusion. An MFR of \u22642 identifies elevated risk, while higher values are associated with improved survival. These findings support the routine integration of MFR to enhance risk stratification in patients with suspected or known coronary artery disease.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/circimaging.125.018729","type":"journal-article","created":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T10:00:13Z","timestamp":1769767213000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":6,"title":["Multicenter Evaluation of Myocardial Flow Reserve as a Prognostic Marker for Mortality in\n                    <sup>13<\/sup>\n                    N-Ammonia PET Myocardial Perfusion Imaging"],"prefix":"10.1161","volume":"19","author":[{"given":"Giselle","family":"Ramirez","sequence":"first","affiliation":[{"name":"Artificial Intelligence in Medicine Research Center, Departments of Biomedical Sciences, Medicine, and Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., V.B., R.J.H.M., M.L., P.J.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-4838-3700","authenticated-orcid":true,"given":"Valerie","family":"Builoff","sequence":"additional","affiliation":[{"name":"Artificial Intelligence in Medicine Research Center, Departments of Biomedical Sciences, Medicine, and Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., V.B., R.J.H.M., M.L., P.J.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4676-2433","authenticated-orcid":true,"given":"Robert J.H.","family":"Miller","sequence":"additional","affiliation":[{"name":"Artificial Intelligence in Medicine Research Center, Departments of Biomedical Sciences, Medicine, and Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., V.B., R.J.H.M., M.L., P.J.S.)."},{"name":"Department of Cardiac Sciences, University of Calgary, Alberta, Canada (R.J.H.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1531-880X","authenticated-orcid":true,"given":"Mark","family":"Lemley","sequence":"additional","affiliation":[{"name":"Artificial Intelligence in Medicine Research Center, Departments of Biomedical Sciences, Medicine, and Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., V.B., R.J.H.M., M.L., P.J.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8764-6012","authenticated-orcid":true,"given":"Isabel","family":"Carvajal-Juarez","sequence":"additional","affiliation":[{"name":"Department of Nuclear Cardiology, Ignacio Chavez National Institute of Cardiology, Mexico City, Mexico (I.C.-J., E.A.)."},{"name":"PET\/CT Unit, Faculty of Medicine, National Autonomous University of Mexico, Mexico City (I.C.-J., E.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erick","family":"Alexanderson","sequence":"additional","affiliation":[{"name":"Department of Nuclear Cardiology, Ignacio Chavez National Institute of Cardiology, Mexico City, Mexico (I.C.-J., E.A.)."},{"name":"PET\/CT Unit, Faculty of Medicine, National Autonomous University of Mexico, Mexico City (I.C.-J., E.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas L.","family":"Rosamond","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City (T.L.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0552-712X","authenticated-orcid":true,"given":"Na","family":"Song","sequence":"additional","affiliation":[{"name":"Department of Radiology (Nuclear Medicine), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY (N.S., M.I.T., L.S.)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0968-2143","authenticated-orcid":true,"given":"Mark I.","family":"Travin","sequence":"additional","affiliation":[{"name":"Department of Radiology (Nuclear Medicine), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY (N.S., M.I.T., L.S.)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3091-3735","authenticated-orcid":true,"given":"Leandro","family":"Slipczuk","sequence":"additional","affiliation":[{"name":"Department of Radiology (Nuclear Medicine), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY (N.S., M.I.T., L.S.)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2583-9278","authenticated-orcid":true,"given":"Andrew J.","family":"Einstein","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Departments of Medicine and Radiology, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York (A.J.E.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samuel B.","family":"Wopperer","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.B.W., P.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3119-025X","authenticated-orcid":true,"given":"Marcelo F.","family":"Di Carli","sequence":"additional","affiliation":[{"name":"Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women\u2019s Hospital, Boston, MA (M.F.D.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3811-8712","authenticated-orcid":true,"given":"Panithaya","family":"Chareonthaitawee","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 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