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

IF 10.3 1区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS JACC. Heart failure Pub Date : 2024-11-21 DOI:10.1016/j.jchf.2024.09.011

Eperke Merkel, Robert Hatala, Mátyás Szigeti, Walter Schwertner, Bálint Lakatos, Anett Behon, Kinga Goscinska-Bis, Goran Milasinovic, Roland Papp, Mihály Ruppert, László Sághy, Marcell Clemens, Scott D Solomon, Valentina Kutyifa, Attila Kovács, Annamária Kosztin, Béla Merkely

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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]; 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).

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HFrEF患者将右心室起搏升级为心脏再同步可改善症状和功能结局。

背景：在布达佩斯（左心室反向重塑双心室升级和左心室功能障碍患者间歇性或永久性心尖/间隔右室起搏的临床结果）-CRT升级随机试验中，作者已经证明，心脏再同步化治疗（CRT）升级后，低射血分数（HFrEF）右心室起搏负担高的心力衰竭患者的死亡率和发病率得到改善。目的：本亚研究旨在探讨CRT升级对症状、功能结局和运动能力的影响。方法：在BUDAPEST-CRT升级试验中，360例使用起搏器或植入式心律转复除颤器（ICD）且RV起搏负担≥20%的HFrEF患者随机（3:2）分配到心脏再同步化治疗与除颤器（CRT-D）升级（n = 215）或ICD （n = 145）。预先指定的第三终点是生活质量（QoL）（EQ-5D-3L）、NYHA功能等级、6分钟步行测试和n端前b型利钠肽（NT-proBNP）水平的变化。结果：与仅ICD组相比，CRT-D升级组的NYHA功能分级在12个月时得到改善(调整OR: 0.50 [95% CI: 0.32-0.80]；P = 0.003)。CRT-D组NT-proBNP水平显著下降(调整差值为-1,257 pg/mL [95% CI: -2,287至-228]；P = 0.017)。年龄相关性生活质量恶化的进展被CRT-D升级所减缓(EQ-5D-3L逐年差异：0.015 [95% CI: 0.005-0.025]；P交互作用= 0.003)。然而，运动耐受性（6分钟步行测试）在两组中保持不变。结论：与单独使用ICD相比，HFrEF合并起搏器/ICD和≥20% RV起搏负担的患者接受CRT升级后，NYHA功能分级有明显改善，利钠肽水平下降。此外，在这些脆弱的老年患者群体中，CRT-D升级可以缓解由于老龄化导致的生活质量恶化的进展。（双心室升级对左心室反向重构和左心室功能障碍患者间歇性或永久性心尖/间隔右心室起搏的临床结果[BUDAPEST]-CRT升级试验）。

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来源期刊

JACC. Heart failure CARDIAC & CARDIOVASCULAR SYSTEMS-

CiteScore

21.20

自引率

2.30%

发文量

164

期刊介绍： JACC: Heart Failure publishes crucial findings on the pathophysiology, diagnosis, treatment, and care of heart failure patients. The goal is to enhance understanding through timely scientific communication on disease, clinical trials, outcomes, and therapeutic advances. The Journal fosters interdisciplinary connections with neuroscience, pulmonary medicine, nephrology, electrophysiology, and surgery related to heart failure. It also covers articles on pharmacogenetics, biomarkers, and metabolomics.