F-18-Fluorodeoxyglucose Positron Emission Tomography Imaging-Assisted Management of Patients With Severe Left Ventricular Dysfunction and Suspected Coronary DiseaseA 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.
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Figure 1 Examples of Reconstructed Polar Maps for 2 Patients
In each set, the top panels are the raw perfusion (left) and raw F-18-fluorodeoxyglucose (FDG) uptake (right) polar maps; the middle panels are the normalized perfusion (left) and FDG uptake (right); the lowest panels are the scar score (left) and mismatch score (right); color scale in the lower panel is shifted to allow visualization of defects (this does not affect the score determinations). (Patient A) Predominantly scar in the anteroseptal are inferolateral walls and apex. Of the total left ventricular (LV) myocardium; 31% was scar and 3% was mismatch. Interpretation was that there was a large scar and a small amount of hibernating viable myocardium and that the patient would not be expected to improve after revascularization. (Patient B) Partial mismatch (mixture of scar and hibernating myocardium) in the large defect involving the inferior wall and apex and extending to the anteroseptal wall. Of the total LV myocardium; 8% was scar and 18% was mismatch. The interpretation was that there was a large amount of hibernating viable myocardium and that the patient would be expected to improve after revascularization.
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Figure 2 Flow Diagram of Recruitment, Randomization, Dropouts, Noncardiac Death, and Events at 1 Year*
*Two patients had cardiac transplant before any other cardiac event and were censored at the time of transplantation. PET = positron emission tomography.
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Figure 3 "Survival Curves" (on the Basis of Time to First Occurring Outcome of the Composite Event)
Mantel-Haenszel (log-rank) test for differences between 2 survival curves; chi-square = 2.1, hazard ratio = 0.78, 95% CI 0.58 to 1.1, p = 0.15. PET = positron emission tomography.
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Figure 4 "Survival" Curves (on the Basis of Time to Cardiac Death) for All Subjects
Mantel-Haenszel (log-rank) test for differences between 2 survival curves; chi-square = 1.3, hazard ratio = 0.72, 95% CI 0.4 to 1.3, p = 0.25. PET = positron emission tomography.
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Figure 5 "Survival Curves" (on the Basis of Time to Cardiac Death) for Patients Without Recent Angiography
Mantel-Haenszel (log-rank) test for differences between 2 survival curves; chi-square = 4.5, hazard ratio = 0.4, 95% CI 0.17 to 0.96, p = 0.035. PET = positron emission tomography.
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Figure 6 Rates of Adherence, Revascularization, and Revascularization Work-Up
(A) Rates of adherence to positron emission tomography recommendations for revascularization or revascularization work-up (*p < 0.05 for moderate vs. others). (B) Rates of revascularization (solid bars); revascularization work-up without revascularization (hatched bars), and no revascularization (open bars). Rates of revascularization + revascularization were different between groups (*p < 0.01 vs. other amounts of viability).
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Figure 7 "Survival Curves" (on the Basis of Time to First Occurring Outcome Out of the Composite Event)
The positron emission tomography adherence group versus standard care arm. Mantel-Haenszel (log-rank) Test for differences between 2 survival curves; adjusted hazard ratio = 0.62, 95% CI 0.42 to 0.93, p = 0.019.
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