Eperke Merkel MD , Robert Hatala MD, PhD , Mátyás Szigeti PhD , Walter Schwertner MD , Bálint Lakatos MD, PhD , Anett Behon MD , Kinga Goscinska-Bis MD , Goran Milasinovic MD , Roland Papp MD , Mihály Ruppert MD, PhD , László Sághy MD, PhD , Marcell Clemens MD, PhD , Scott D. Solomon MD , Valentina Kutyifa MD, PhD , Attila Kovács MD, PhD , Annamária Kosztin MD, PhD , Béla Merkely MD, PhD
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Solomon MD , Valentina Kutyifa MD, PhD , Attila Kovács MD, PhD , Annamária Kosztin MD, PhD , Béla Merkely MD, PhD","doi":"10.1016/j.jchf.2024.09.011","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Objectives</h3><div>This substudy sought to examine the impact of CRT upgrade on symptoms, functional outcome, and exercise capacity.</div></div><div><h3>Methods</h3><div>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.</div></div><div><h3>Results</h3><div>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]; <em>P =</em> 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]; <em>P =</em> 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]; <em>P</em> interaction = 0.003). However, exercise tolerance (6-minute walk test) remained unchanged in both groups.</div></div><div><h3>Conclusions</h3><div>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; <span><span>NCT02270840</span><svg><path></path></svg></span>)</div></div>","PeriodicalId":14687,"journal":{"name":"JACC. 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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.</div></div><div><h3>Results</h3><div>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]; <em>P =</em> 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]; <em>P =</em> 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]; <em>P</em> interaction = 0.003). 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Upgrading Right Ventricular Pacing to Cardiac Resynchronization in HFrEF Patients Improves Symptoms and Functional Outcomes
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)
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.
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