CRT upgrade benefits patients with HFrEF and an ICD

An upgrade from an implantable cardioverter-defibrillator (ICD) to a cardiac resynchronisation therapy defibrillator (CRT-D) was associated with a reduced risk for cardiovascular and other adverse outcomes in patients with heart failure with reduced ejection fraction (HFrEF) and right ventricular (RV) pacing. Based on these results from the BUDAPEST CRT Upgrade trial, the authors believed that patients with HFrEF with a pacemaker or ICD and RV pacing should immediately receive a CRT upgrade. However, the sample size of this study was small and larger studies are needed to confirm these findings.

“It has not been established whether an upgrade from a pacemaker or an ICD to a CRT offers benefits for patients with HFrEF,” said Dr Béla Merkely (Semmelweis University, Hungary) [1]. According to Dr Merkely, the lack of data on hard outcomes from large trials led to several modifications of CRT guidelines in the last decade. “This demonstrates the need for more robust evidence,” he argued. “Furthermore,” Dr Merkely claimed, “in 60% of the patients, an indicated upgrade is not performed or postponed to a later, often undetermined date.”

The multicentre, randomised-controlled BUDAPEST CRT Upgrade trial (NCT02270840) evaluated the efficacy and safety of a CRT-D upgrade in patients with HFrEF and intermittent or permanent RV pacing who already had an ICD [1,2]. Participants had HFrEF, a prior pacemaker or ICD, RV pacing of 20–100%, and a paced QRS complex ≥150 ms (n=360) and were randomised 3:2 to a CRT-D upgrade or no upgrade. The composite primary endpoint was the first occurrence of HF hospitalisation, all-cause mortality, or <15% reduction in left ventricular end-systolic volume (LVESV) at month 12.

After 12 months, 78.9% of participants in the no-intervention arm had experienced a primary endpoint event, whereas only 32.4% of the participants in the CRT-D arm had one of the primary outcome events (adjusted OR 0.11; 95% CI 0.06–0.19; P<0.001). The secondary outcome of all-cause mortality or HF hospitalisation favoured the CRT-D arm over the no-intervention arm as well (adjusted HR 0.27; 95% CI 0.16–0.47; P<0.001). For mortality alone the adjusted HR was 0.52 (95% CI 0.23–1.19).

“These results show that patients with HFrEF with a pacemaker or ICD and intermittent or permanent RV pacing should receive a CRT upgrade without delay to reduce the risk for serious adverse events,” according to Prof. Merkely. Even though the results of this open-label trial were impressive, larger studies are needed to confirm whether the investigated intervention really reduces mortality in this population.

1. 
   
   1. Merkely B, et al. Cardiac resynchronisation therapy upgrade in heart failure with right ventricular pacing: a multicentre, randomised, controlled trial. Hot Line Session 2, ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.
   2. Merkely B, et al. Eur Heart J. 2023; Aug 26. DOI: 1093/eurheartj/ehad591.

 

Copyright ©2023 Medicom Medical Publishers



Posted on 30 October 202330 October 2023