Upgrading Right Ventricular Pacing to Cardiac Resynchronization in HFrEF Patients Improves Symptoms and Functional...

Area of Science:

• Cardiology
• Electrophysiology
• Heart Failure Management

Background:

• High right ventricular (RV) pacing burden in patients with heart failure with reduced ejection fraction (HFrEF) can lead to adverse remodeling.
• Cardiac resynchronization therapy (CRT) has shown benefits in HFrEF, but its role as an upgrade in patients with high RV pacing is less understood.

Purpose of the Study:

• To evaluate the impact of CRT upgrade on symptoms, functional status, and exercise capacity in HFrEF patients with significant RV pacing.
• To assess changes in quality of life (QoL), NYHA functional class, 6-minute walk test, and NT-proBNP levels.

Main Methods:

• The BUDAPEST-CRT Upgrade trial randomized 360 HFrEF patients with ≥20% RV pacing to either CRT with defibrillator (CRT-D) upgrade or standard ICD.
• Tertiary endpoints included changes in EQ-5D-3L for QoL, NYHA class, 6-minute walk test, and NT-proBNP levels over 12 months.

Main Results:

• CRT-D upgrade led to significant improvement in NYHA functional class compared to ICD alone (OR: 0.50; P=0.003).
• A notable reduction in NT-proBNP levels was observed in the CRT-D arm (difference: -1,257 pg/mL; P=0.017).
• CRT-D upgrade moderated the age-related decline in QoL (P-interaction=0.003), but exercise tolerance (6-minute walk test) remained unchanged.

Conclusions:

• In HFrEF patients with high RV pacing burden, CRT upgrade significantly improves functional class and reduces natriuretic peptide levels compared to ICD alone.
• CRT-D upgrade offers a potential strategy to mitigate worsening quality of life associated with aging in this patient population.