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EXPEDITED PUBLICATION

F-18-Fluorodeoxyglucose Positron Emission Tomography Imaging-Assisted Management of Patients With Severe Left Ventricular Dysfunction and Suspected Coronary Disease

A Randomized, Controlled Trial (PARR-2)

Rob S.B. Beanlands, MD, FRCPC, FACC^_*,_*, Graham Nichol, MD, FRCPC, Ella Huszti, MSc^¶, Dennis Humen, MD, FRCPC, FACP, FACC, Normand Racine, MD, FRCPC^#, Michael Freeman, MD, FACC, FRCPC, Karen Y. Gulenchyn, MD, FRCPC^||, Linda Garrard, BSc, RN^_*, Robert deKemp, PhD^_*, Ann Guo, MEng^_*, Terrence D. Ruddy, MD, FRCPC, FACC^_*, Francois Benard, MD, FRCPC^_**, André Lamy, MD, MHSc^||, Robert M. Iwanochko, MD, FRCPC, FACC the PARR-2 Investigators

^_* National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
Division of Cardiology, London Health Sciences Center, London, Ontario, Canada
Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
Division of Cardiology, Toronto Hospital, University of Toronto Health Sciences Network, Toronto, Ontario, Canada
^|| ES Garnett Memorial PET Center, Department of Nuclear Medicine and the Division of Cardiac Surgery, Hamilton Health Sciences, Hamilton, Ontario, Canada
^¶ Epidemiology and Biostatistics Department, McGill University, Montréal, Québec, Canada
^# Division of Cardiology, Montréal Heart Institute, Montréal, Québec, Canada
^_** Division of Nuclear Medicine, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
University of Washington—Harborview Center for Prehospital Emergency Care, Seattle, Washington.
The PARR-2 Investigators were affiliated with the previously mentioned institutions in addition to the following: the Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Division of Cardiology, Toronto Western Hospital, University of Toronto, Ontario, Canada; Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and the Division of Cardiology, Hopital Laval, Universitaire de Laval, Québec City, Québec, Canada.

Manuscript received July 5, 2007; revised manuscript received August 23, 2007, accepted September 7, 2007.

^_* Reprint requests and correspondence: Dr. Rob S. Beanlands, National Cardiac PET Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7 Canada. (Email: rbeanlands{at}ottawaheart.ca).

Objectives: We conducted a randomized trial to assess the effectiveness of F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET)-assisted management in patients with severe ventricular dysfunction and suspected coronary disease.

Background: Such patients may benefit from revascularization, but have significant perioperative morbidity and mortality. F-18-fluorodeoxyglucose PET can detect viable myocardium that might recover after revascularization.

Methods: Included were patients with severe left ventricular (LV) dysfunction and suspected coronary disease being considered for revascularization, heart failure, or transplantation work-ups or in whom PET was considered potentially useful. Patients were stratified according to recent angiography or not, then randomized to management assisted by FDG PET (n = 218) or standard care (n = 212). The primary outcome was the composite of cardiac death, myocardial infarction, or recurrent hospital stay for cardiac cause, within 1 year.

Results: At 1 year, the cumulative proportion of patients who had experienced the composite event was 30% (PET arm) versus 36% (standard arm) (relative risk 0.82, 95% confidence interval [CI] 0.59 to 1.14; p = 0.16). The hazard ratio (HR) for the composite outcome, PET versus standard care, was 0.78 (95% CI 0.58 to 1.1; p = 0.15); for patients that adhered to PET recommendations for revascularization, revascularization work-up, or neither, HR = 0.62 (95% CI 0.42 to 0.93; p = 0.019); in those without recent angiography, for cardiac death, HR = 0.4 (95% CI 0.17 to 0.96; p = 0.035).

Conclusions: This study did not demonstrate a significant reduction in cardiac events in patients with LV dysfunction and suspected coronary disease for FDG PET-assisted management versus standard care. In those who adhered to PET recommendations and in patients without recent angiography, significant benefits were observed. The utility of FDG PET is best realized in this subpopulation and when adherence to recommendations can be achieved.

Abbreviations and Acronyms   CABG = coronary artery bypass graft   CAD = coronary artery disease   CI = confidence interval   EF = ejection fraction   FDG = F-18-fluorodeoxyglucose   HR = hazard ratio   LV = left ventricle/ventricular   MI = myocardial infarction   MRI = magnetic resonance imaging   PET = positron emission tomography   RVG = radionuclide ventriculography

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