3
|
Jabbour RJ, Shun-Shin MJ, Finegold JA, Afzal Sohaib SM, Cook C, Nijjer SS, Whinnett ZI, Manisty CH, Brugada J, Francis DP. Effect of study design on the reported effect of cardiac resynchronization therapy (CRT) on quantitative physiological measures: stratified meta-analysis in narrow-QRS heart failure and implications for planning future studies. J Am Heart Assoc 2015; 4:e000896. [PMID: 25564370 PMCID: PMC4330047 DOI: 10.1161/jaha.114.000896] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Biventricular pacing (CRT) shows clear benefits in heart failure with wide QRS, but results in narrow QRS have appeared conflicting. We tested the hypothesis that study design might have influenced findings. Method and Results We identified all reports of CRT‐P/D therapy in subjects with narrow QRS reporting effects on continuous physiological variables. Twelve studies (2074 patients) met these criteria. Studies were stratified by presence of bias‐resistance steps: the presence of a randomized control arm over a single arm, and blinded outcome measurement. Change in each endpoint was quantified using a standardized effect size (Cohen's d). We conducted separate meta‐analyses for each variable in turn, stratified by trial quality. In non‐randomized, non‐blinded studies, the majority of variables (10 of 12, 83%) showed significant improvement, ranging from a standardized mean effect size of +1.57 (95%CI +0.43 to +2.7) for ejection fraction to +2.87 (+1.78 to +3.95) for NYHA class. In the randomized, non‐blinded study, only 3 out of 6 variables (50%) showed improvement. For the randomized blinded studies, 0 out of 9 variables (0%) showed benefit, ranging from −0.04 (−0.31 to +0.22) for ejection fraction to −0.1 (−0.73 to +0.53) for 6‐minute walk test. Conclusions Differences in degrees of resistance to bias, rather than choice of endpoint, explain the variation between studies of CRT in narrow‐QRS heart failure addressing physiological variables. When bias‐resistance features are implemented, it becomes clear that these patients do not improve in any tested physiological variable. Guidance from studies without careful planning to resist bias may be far less useful than commonly perceived.
Collapse
Affiliation(s)
- Richard J Jabbour
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - S M Afzal Sohaib
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Christopher Cook
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Sukhjinder S Nijjer
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Zachary I Whinnett
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Charlotte H Manisty
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Josep Brugada
- Hospital Clinic, University of Barcelona, Barcelona, Spain (J.B.)
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| |
Collapse
|
4
|
Thibault B, Harel F, Ducharme A, White M, Ellenbogen KA, Frasure-Smith N, Roy D, Philippon F, Dorian P, Talajic M, Dubuc M, Guerra PG, Macle L, Rivard L, Andrade J, Khairy P. Cardiac Resynchronization Therapy in Patients With Heart Failure and a QRS Complex <120 Milliseconds. Circulation 2013; 127:873-81. [PMID: 23388213 DOI: 10.1161/circulationaha.112.001239] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background—
Although the benefits of cardiac resynchronization therapy are well established in selected patients with heart failure and a prolonged QRS duration, salutary effects in patients with narrow QRS complexes remain to be demonstrated.
Methods and Results—
The Evaluation of Resynchronization Therapy for Heart Failure (LESSER-EARTH) trial is a randomized, double-blind, 12-center study that was designed to compare the effects of active and inactive cardiac resynchronization therapy in patients with severe left ventricular dysfunction and a QRS duration <120 milliseconds. The trial was interrupted prematurely by the Data Safety and Monitoring Board because of futility and safety concerns after 85 patients were randomized. Changes in exercise duration after 12 months were no different in patients with and without active cardiac resynchronization therapy (−0.7 minutes [95% confidence interval (CI), −2.9 to 1.5] versus 0.8 minutes [95% CI, −1.2 to 2.9];
P
=0.31]. Similarly, no significant differences were observed in left ventricular end-systolic volumes (−6.4 mL [95% CI, −18.8 to 5.9] versus 3.1 mL [95% CI, −9.2 to 15.5];
P
=0.28) and ejection fraction (3.3% [95% CI, 0.7–6.0] versus 2.1% [95% CI, −0.5 to 4.8];
P
=0.52). Moreover, cardiac resynchronization therapy was associated with a significant reduction in the 6-minute walk distance (−11.3 m [95% CI, −31.7 to 9.7] versus 25.3 m [95% CI, 6.1–44.5];
P
=0.01), an increase in QRS duration (40.2 milliseconds [95% CI, 34.2–46.2] versus 3.4 milliseconds [95% CI, 0.6–6.2];
P
<0.0001), and a nonsignificant trend toward an increase in heart failure–related hospitalizations (15 hospitalizations in 5 patients versus 4 hospitalizations in 4 patients).
Conclusions—
In patients with a left ventricular ejection fraction ≤35%, symptoms of heart failure, and a QRS duration <120 milliseconds, cardiac resynchronization therapy did not improve clinical outcomes or left ventricular remodeling and was associated with potential harm.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00900549.
Collapse
Affiliation(s)
- Bernard Thibault
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - François Harel
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Anique Ducharme
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Michel White
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Kenneth A. Ellenbogen
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Nancy Frasure-Smith
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Denis Roy
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - François Philippon
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Paul Dorian
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Mario Talajic
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Marc Dubuc
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Peter G. Guerra
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Laurent Macle
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Léna Rivard
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Jason Andrade
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Paul Khairy
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| |
Collapse
|