Pharmacokinetics of radioiodinated fatty acid myocardial imaging agents in animal models and human studies

Since the oxidation of long chain fatty acids is the major pathway for energy production for the normoxic myocardium, the use of radiolabeled fatty acids for myocardial imaging continues to be a major area of both basic and clinical research. This paper focuses on a discussion of the kinetics of myocardial uptake of radioiodinated fatty acids, including planar and SPECT imaging of various iodine-123-labeled analogues, and data from animal and isolated heart studies, and where possible, comparison with results of clinical studies. Key examples include iodoalkyl-substituted straight chain fatty acids such as 17-IHDA (17-iodoheptadecanoic acid). These analogues are rapidly metabolized in the myocardium, resulting in release of free radioiodide, and can only be practically used for planar imaging. Terminal iodophenyl-substituted fatty acids illustrate a successful approach of stabilizing radioiodine to overcome the release of free iodide encountered with the straight-chain analogues. These analogues, exemplified by p-IPPA [15-(p-iodophenyl)pentadecanoic acid], are widely used in clinical practice. Although washout can be delayed by increase in the arterial lactate levels by mild exercise, SPECT imaging must still be carefully timed. In contrast to these examples, the ortho iodide-substituted IPPA isomer (ortho- instead of para-phenyl substitution of radioiodide) is a unique example which shows rapid myocardial washout in laboratory animals but nearly irreversible retention in humans. Introduction of methyl-branching is a major important approach which has been successfully used to alter tracer kinetics of radioiodinated fatty acids by increasing myocardial retention. A key example in this class of compounds is 3-(R,S)-BMIPP [15-(p-iodophenyl)-3 (R,S)-methylpentadecanoic acid], an analogue of p-IPPA in which methyl-branching has been introduced into the β-position of the carbon chain. Although tracer washout is significantly delayed with this structural perturbation, a large number of clinical studies have shown that slow myocardial washout is still observed. Detailed biochemical studies with radioiodinated 3-BMIPP have demonstrated that initial α-oxidation produces a metabolite that can then be catabolized by α-oxidation. An unexpected and important observation with the [¹²³I]-3-(R,S)-BMIPP agent has been the mis-match between perfusion tracer distribution and the regional BMIPP distribution which has been widely observed in jeopardized, but viable myocardial regions. Another example in the methyl-branched series is DMIPP [15-(p-iodophenyl)-3,3-dimethylpentadecanoic acid], which has very prolonged myocardial retention and slow washout kinetics although only animal studies have been reported with this agent. Still another more recent approach has been the synthesis and laboratory animal and human evaluation of analogues containing a phenylene bridge in the fatty acid chain. One example is 3-10 [13-(4'-iodophenyl)]-3-(p-phenylene)tridecanoic acid (PHIPA 3-10), which has also proven successful in delaying myocardial tracer washout. This paper focuses on a discussion of the effects of molecular structure on the myocardial uptake and release kinetics of these various radioiodinated fatty acid analogues.