Top Banner
Improvements in Clinical outcome with biventricular versus Right ventricular Pacing The Block HF study JACC May 2016 Dr Joura Vishal
57

BLOCK HF trial

Feb 21, 2017

Download

Health & Medicine

Joura Vishal
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: BLOCK HF trial

Improvements in Clinical outcome with biventricular versus Right

ventricular Pacing

The Block HF study

JACC May 2016

Dr Joura Vishal

Page 2: BLOCK HF trial

Introduction • Heart failure : end stage of various cardiac

conditions

• Refractory heart failure : symptoms at rest inspite of diet , fluid modifications and Optimal medical therapy ( OMT )

• Affects 2.5 % in United states and european countries

2.5 to 5 million in India

Page 3: BLOCK HF trial

Introduction • Systolic heart failure may have - intraventricular dyssynchrony - interventricular dyssynchrony - atriventricular dysnchrony

These patients are at high risk of refractory heart failure and suden cardiac death Baldasseroni et al Am Heart J 2002

Page 4: BLOCK HF trial
Page 5: BLOCK HF trial

Introduction

Cardiac resynchronization therapy • minimises regional left ventricular delay • Reduces Mitral regurgitation • Normalises neurohormonal factors

Thus altering the natural history of disease Mc Alister FA et al JAMA 2007

Page 6: BLOCK HF trial

Introduction

Biventricular pacing is a/w - improved QOL - increased functional capacity - reducing hospitalization - Improved survival

Page 7: BLOCK HF trial

The Block HF trial

RV pacing lead to worse clinic outcomes compared to low rate ventricular pacing in patients with pacemakers and ICD who have intact AV conduction

In AV block pacing is required all the time

Page 8: BLOCK HF trial

Hypothesis In patients with AV block , LVEF < 50% , NYHA class I , NYHA II

Biventricular pacing would be superior to RV pacing with respect to • combined end point of death • heart failure related urgent care • adverse LV remodeling manifested by a > 15 %

LVESV index

Page 9: BLOCK HF trial

NEJM 2013

Page 10: BLOCK HF trial
Page 11: BLOCK HF trial

Methods • Prospective • Multicenter ( 58 sites in United States & 2 in

Canada ) • Randomized • Double blind

Page 12: BLOCK HF trial

Methods • 918 patients were enrolled from Dec 2003 till Nov

2011• 691 randomized • Follow up average 37 months

Statistical analysis : Bayesian statistical method was used with pre specified metric of benefit being : posterior probability > 0.95

Page 13: BLOCK HF trial
Page 14: BLOCK HF trial

Methods

Eligibility criteria

• Class I / IIa indication for pacing • NYHA I – NYHA III heart failure • LVEF less than 50%

Page 15: BLOCK HF trial

Methods

Exclusion criteria • Previous receipt of CRT • Unstable angina • Acute MI • PCI / CABG in last 30 days • Valvular disease with indication for surgery /

repair

Page 16: BLOCK HF trial

Methods • Implanted pacemaker with or without ICD with

biventricular pacing capability • RV pacing for 30 -60days while OMT was given

• In patients without atrial arrhythmias atrial lead was also implanted for atrial synchronized RV or biventricular pacing

Page 17: BLOCK HF trial
Page 18: BLOCK HF trial
Page 19: BLOCK HF trial

Methods

• Echocardiographic examination was done at baseline then at 6 , 12, 18 and 24 months

Prespecified outcomes: • Packer clinical composite score • QOL• NYHA functional class

Page 20: BLOCK HF trial

Packer composite clinical score

Worsened • Died • Experienced a hospitalization• Worsening of NYHA class Improved Improvement in NYHA class Reduced symptoms Unchanged : none of the above criteria met

Page 21: BLOCK HF trial

Results

Page 22: BLOCK HF trial

Packer composite clinical score

Page 23: BLOCK HF trial

NYHA class at baseline

Page 24: BLOCK HF trial

NYHA functional status

Page 25: BLOCK HF trial

NYHA functional status in Crossovers

Page 26: BLOCK HF trial

QOL

Page 27: BLOCK HF trial

QOL

Page 28: BLOCK HF trial

Discussion

Page 29: BLOCK HF trial
Page 30: BLOCK HF trial

Miracle trial • 453 patients • Moderate to severely symptomatic • LVEF <35%• QRS >130ms

Assessed for NYHA class ; QOL ; 6min walk distance CRT arm versus no CRT with OMT

Page 31: BLOCK HF trial

Miracle trial : results

Significant improvement in • 6 minute walk distance • QOL• Time on treadmill• Ejection fraction • Required fewer hospitalization / iv medications

Page 32: BLOCK HF trial

Miracle trial

Effects similar to those seen with beta blockers in heart failure were seen in this trial but these effects

were seen with CRT who were already on beta blockers

Page 33: BLOCK HF trial

Miracle trial

Page 34: BLOCK HF trial

COMPANION TRIAL

NEJM 2004

Page 35: BLOCK HF trial
Page 36: BLOCK HF trial

COMPANION TRIAL

Page 37: BLOCK HF trial

CARE HF trial

Page 38: BLOCK HF trial

CARE HF trial • 82 European centers • Jan 2001 to march 2003 • non blinded trial • CRT versus OMT

Eligible patients ( 404 to CRT ; 409 to OMT ) • NYHA III –IV on OMT • LVEF <35%• LVEDD at least 30mm • QRS >120ms

Page 39: BLOCK HF trial
Page 40: BLOCK HF trial

Kaplan Meir estimate of primary end

outcome

Page 41: BLOCK HF trial

Kaplan Meir estimate of primary secondary

outcome

Page 42: BLOCK HF trial

REVERSE trial

Page 43: BLOCK HF trial

Reverse Trial • 610 patients • NYHA class I / II • QRS >120ms• LVEF < 40%

Received CRT +/- D

Page 44: BLOCK HF trial

Reverse Trial • Clinical composite score • LV systolic volume index

Results : Significant improvement in LV systolic index Fewer hospitalization

Page 45: BLOCK HF trial

Reverse Trial Conclusion :

CRT reduces the hospitalization in HF patients and improves ventricular structure and function in NYHA class I and II with ventricular dyssynchrony

Page 46: BLOCK HF trial

MADIT CRT trial

Page 47: BLOCK HF trial

MADIT CRT trial

Page 48: BLOCK HF trial

MADIT CRT trial

Page 49: BLOCK HF trial

MADIT CRT trial Conclusion

CRT D versus ICD alone • Reduced heart failure events • Females benefit more than males • QRS >150 benefit more • Patients with LBBB show a significant reduction in

VT /VF and death compared to non LBBB

Page 50: BLOCK HF trial

RAFT trial

Page 51: BLOCK HF trial

RAFT trial

Page 52: BLOCK HF trial

RAFT trial

Page 53: BLOCK HF trial
Page 54: BLOCK HF trial
Page 55: BLOCK HF trial

Updated CRT guidelines

• Limitation of class I indication to QRS >150ms • Limitation of class I indication to LBBB • Expansion of class I indication to NYHA II and with

LBBB with QRS >150ms• Addition of class IIb recommendation who have - LVEF <30% - Ischemic HF - Sinus rhythm - LBBB with QRS > 150 ms - NYHA I

Page 56: BLOCK HF trial
Page 57: BLOCK HF trial