Immediate upgrade to cardiac resynchronization therapy defibrillator is recommended for patients with HFrEF with RV pacing to reduce adverse outcomes.

An upgrade from an implantable cardioverter-defibrillator (ICD) to a cardiac resynchronization therapy defibrillator (CRT-D) reduced the 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 BUDAPEST CRT Upgrade results, the authors concluded that patients with HFrEF with a pacemaker or ICD and RV pacing should receive a CRT upgrade immediately.

The multicenter, randomized controlled BUDAPEST CRT Upgrade trial 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. Patients with HFrEF, a prior pacemaker or ICD, RV pacing of 20% to 100%, and a paced QRS complex of 150 milliseconds or greater (n=360) were randomly assigned 3:2 to a CRT-D upgrade or no upgrade. The composite primary endpoint was the first occurrence of HF hospitalization, all-cause mortality, or less than 15% reduction in left ventricular end-systolic volume (LVESV) from baseline to month 12. Béla Merkely, MD, PhD, presented the primary results at ESC Congress 2023.

After 12 months, 78.9% of participants in the no-intervention arm 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 hospitalization favored the CRT-D arm over the no-intervention arm as well (adjusted HR, 0.27; 95% CI, 0.16–0.47; P<0.001).

“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,” concluded Dr. Merkely.

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