title: Evaluation of outcome and cost-effectiveness using an FDG PET-guided approach to management of patients with coronary disease and severe left ventricular dysfunction (PARR-2): rationale, design, and methods.
abstract: Patients with severe ventricular dysfunction and coronary disease have high morbidity and mortality. They may benefit from revascularization but have significant perioperative morbidity and mortality. Positron emission tomography (PET) imaging with F-18-fluorodeoxyglucose (FDG) can detect viable myocardium that may recover from revascularization in such patients. It is unclear whether use of FDG PET in this population improves outcome or is cost-effective. The principal aim of this study is to determine whether FDG PET-guided therapy improves clinical outcome compared to standard care. Secondary objectives are to determine whether FDG PET-guided therapy improves left ventricular (LV) function, improves quality of life, and provides a cost benefit versus standard care. Included in this multicenter randomized controlled trial are patients with coronary artery disease and severe LV dysfunction who are referred for revascularization, heart failure, or cardiac transplantation or in whom FDG PET is potentially useful. Consenting subjects will be randomized to therapy directed by FDG PET or standard care. The primary outcome is the composite cardiovascular endpoint of cardiac death, myocardial infarction, transplantation, or rehospitalization for unstable angina or heart failure. Secondary outcomes include health-related quality of life, costs, mortality, cardiovascular events, and LV function. Assuming two-sided alpha=0.05, power=80%, a sample size of 206 patients per group is required to detect a 15% absolute difference in the primary outcome between PET-directed therapy compared to standard care. Analyses will be conducted on an intention-to-treat basis. To our knowledge, this is the first large trial to evaluate whether FDG PET-directed therapy is effective and provides a cost benefit in patients with severe LV dysfunction. If so, thousands of such patients can be risk-stratified to select who is likely to benefit from revascularization.
authors.affiliation: Cardiac PET Center, Divisions of Cardiology and Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. rbeanlands@ottawaheart.ca
authors.forename: Rob
authors.initials: R
authors.lastname: Beanlands
authors.forename: Graham
authors.initials: G
authors.lastname: Nichol
authors.forename: Terrence D
authors.initials: TD
authors.lastname: Ruddy
authors.forename: Robert A
authors.initials: RA
authors.lastname: deKemp
authors.forename: Paul
authors.initials: P
authors.lastname: Hendry
authors.forename: Dennis
authors.initials: D
authors.lastname: Humen
authors.forename: Normand
authors.initials: N
authors.lastname: Racine
authors.forename: Heather
authors.initials: H
authors.lastname: Ross
authors.forename: Francois
authors.initials: F
authors.lastname: Benard
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Coates
authors.forename: Robert M
authors.initials: RM
authors.lastname: Iwanochko
authors.forename: Ernest
authors.initials: E
authors.lastname: Fallen
authors.forename: George
authors.initials: G
authors.lastname: Wells
mesh_terms: D003362:Cost-Benefit Analysis; D019788:Fluorodeoxyglucose F18; D006801:Humans; D015337:Multicenter Studies as Topic / Q000379:methods*; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging / Q000601:surgery*; D009204:Myocardial Revascularization; D016032:Randomized Controlled Trials as Topic / Q000379:methods*; D012107:Research Design; D025321:Surgery, Computer-Assisted; D014055:Tomography, Emission-Computed / Q000191:economics; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000601:surgery*
chemical_list: D019788:Fluorodeoxyglucose F18