Upgrading Right Ventricular Pacing to Cardiac Resynchronization in HFrEF Patients Improves Symptoms and Functional Outcomes
- PMID: 39614838
- DOI: 10.1016/j.jchf.2024.09.011
Upgrading Right Ventricular Pacing to Cardiac Resynchronization in HFrEF Patients Improves Symptoms and Functional Outcomes
Abstract
Background: In the BUDAPEST (Biventricular Upgrade on left ventricular reverse remodeling and clinical outcomes in patients with left ventricular Dysfunction and intermittent or permanent APical/SepTal right ventricular pacing)-CRT Upgrade randomized trial, the authors have demonstrated improved mortality and morbidity after cardiac resynchronization therapy (CRT) upgrade in patients with heart failure with reduced ejection fraction (HFrEF) with high right ventricular (RV) pacing burden.
Objectives: This substudy sought to examine the impact of CRT upgrade on symptoms, functional outcome, and exercise capacity.
Methods: In the BUDAPEST-CRT Upgrade trial, 360 HFrEF patients with pacemaker or implantable cardioverter-defibrillator (ICD) and ≥20% RV pacing burden were randomly assigned (3:2) to cardiac resynchronization therapy with defibrillator (CRT-D) upgrade (n = 215) or ICD (n = 145). The prespecified tertiary endpoints were changes in quality of life (QoL) (EQ-5D-3L), NYHA functional class, 6-minute walk test, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels.
Results: Up to 12 months, NYHA functional class improved in the CRT-D upgrade arm compared with ICD only (adjusted OR: 0.50 [95% CI: 0.32-0.80]; P = 0.003). A remarkable decrease was observed in NT-proBNP levels in the CRT-D arm (adjusted difference: -1,257 pg/mL [95% CI: -2,287 to -228 pg/mL]; P = 0.017). The progression of age-related worsening of QoL was moderated by CRT-D upgrade (EQ-5D-3L difference by each year: 0.015 [95% CI: 0.005-0.025]; P interaction = 0.003). However, exercise tolerance (6-minute walk test) remained unchanged in both groups.
Conclusions: HFrEF patients with pacemaker/ICD and ≥20% RV pacing burden receiving CRT upgrade showed a substantial improvement in NYHA functional class and decrease in natriuretic peptide levels, as compared with ICD alone. Moreover, CRT-D upgrade could moderate the progression of worsening of QoL attributed to ageing in this vulnerable, elderly patient population. (Biventricular Upgrade on left ventricular reverse remodeling and clinical outcomes in patients with left ventricular Dysfunction and intermittent or permanent APical/SepTal right ventricular pacing [BUDAPEST]-CRT Upgrade trial; NCT02270840).
Keywords: CRT upgrade; HFrEF; NYHA; QoL; exercise capacity; natriuretic peptides.
Copyright © 2025. Published by Elsevier Inc.
Conflict of interest statement
Funding Support and Author Disclosures The BUDAPEST CRT Upgrade study was an investigator-initiated research trial, sponsored by Semmelweis University, receiving an unrestricted grant from Boston Scientific to conduct the study. The trial was supported by the National Heart Program (Project number NVKP_16-1–2016-0017) with support provided by the National Research Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. Additionally, Project number RRF-2.3.1-21-2022-00003 has been implemented with the support provided by the European Union. Dr Hatala has received institutional grants from Abbott, Biotronik, and Slovak Research and Development Agency; honoraria from Abbott and Medtronic; travel grants from the European Society of Cardiology and Pfizer; and he is also the president of the Slovak Heart Rhythm Association. Dr Papp has received payment or honoraria from Medtronic and Biotronik for lectures and presentations. Dr Solomon has received grants to his institution from Actelion, Alnylam, Amgen, AstraZeneca, Bellerophon, Bayer, BMS, Celladon, Cytokinetics, Eidos, Gilead, GSK, Ionis, Lilly, Mesoblast, MyoKardia, NIH/NHLBI, Neurotronik, Novartis, NovoNordisk, Respicardia, Sanofi Pasteur, Theracos, and US2.AI; and consulting fees outside of the scope of the current work from Abbott, Action, Akros, Alnylam, Amgen, Arena, AstraZeneca, Bayer, Boehringer Ingelheim, BMS, Cardior, Cardurion, Corvia, Cytokinetics, Daiichi-Sankyo, GSK, Lilly, Merck, Myokardia, Novartis, Roche, Theracos, Quantum Genomics, Cardurion, Janssen, Cardiac Dimensions, Tenaya, Sanofi-Pasteur, Dinaqor, Tremeau, CellProThera, Moderna, American Regent, Sarepta, Lexicon, Anacardio, Akros, and Valo. Dr Kutyifa has received grants from Boston Scientific, ZOLL, Biotronik, Spire Inc, and NIH; consulting fees from Biotronik and Zoll; and payment or honoraria for lectures from Abbott Medical and Medtronic. Dr Kovács has received grants from Bolyai Research Scholarship and FK ‘OTKA’ Research Grant from NKFIH outside of the submitted work; stock from CardioSight Inc, and stock option from Argus Cognitive Inc outside of the submitted work; and personal fees from Argus Cognitive, Inc, and CardioSight Hungary LLC outside of the submitted work. Dr Kosztin has received grants from Bolyai Research Scholarship outside of the submitted work; consulting fees from Medtronic; honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, Biotronik, and Novartis; payment for expert testimony from Boehringer Ingelheim and Boston Scientific; travel grants from AstraZeneca and Novartis; participation on a data safety monitoring board or advisory board for Boehringer Ingelheim and Boston Scientific; and role in other board and committee (committee member of Hungarian Society of Cardiology and secretary of the Working Group on Cardiac Arrhythmias and Pacing, Hungarian Society of Cardiology). Dr Merkely has received speaker fees from Boehringer Ingelheim, Daiichi Sankyo, DUKE Clinical Institut, and Novartis; and has received institutional grants for the Heart and Vascular Center of Semmelweis University from Boston Scientific, Biotronik, Boehringer Ingelheim, DUKE Clinical Institut, Eli Lilly, and Novartis; grants from Boston Scientific, NRDIF Hungary, and National Heart Program during the conduct of the study; personal fees from Biotronik, Abbott, AstraZeneca, Novartis, and Boehringer Ingelheim; and grants from Medtronic outside of the submitted work. TKP2021-NVA-12 has been implemented with the support provided by the Ministry of Innovation and Technology of Hungary from the National Research, Development and Innovation Fund, financed under the TKP2021-NVA funding scheme. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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