CRT-D upgrade significantly decreased the risk of the primary composite endpoint regardless of baseline frailty status and led to a significant 0.03-point greater reduction in mean Frailty Index compared to ICD alone.
RCT (n=360)
3:2
Does CRT-D upgrade improve frailty status and reduce the composite of mortality, HF hospitalization, or lack of LV reverse remodeling in patients with HFrEF and RV pacing?
CRT-D upgrade in HFrEF patients with high RV pacing burden improves frailty status and reduces adverse clinical outcomes regardless of baseline frailty.
Odds Ratio: 0.08 (95% CI 0.04–0.19)
Absolute Event Rate: 34.4% vs 86.4%
p-value: p=< 0.001
Frailty and heart failure (HF) both have become increasingly prevalent and each adversely affects prognosis. Data regarding the potential frailty-modifying effect of cardiac resynchronization therapy (CRT) upgrade remain scarce. This study aimed to evaluate the impact of frailty on clinical outcomes in the Budapest-CRT Upgrade trial population. Patients with heart failure and reduced ejection fraction (HFrEF), an implanted pacemaker or implantable cardioverter-defibrillator (ICD) and ≥ 20% right ventricular pacing burden were randomized to CRT-D upgrade (n = 215) or ICD alone (n = 145). Our primary endpoint was all-cause mortality, HF-hospitalization and or < 15% reduction of left ventricular end-systolic volume at 12 months. Frailty was assessed using a 31-item frailty index (FI) based on the Rockwood method, and patients were dichotomized according to the median FI. Among 360 patients, the mean baseline FI was 0.39 ± 0.10, with follow-up FI available in 282 patients at 12 months. CRT-D upgrade significantly decreased the risk of the primary endpoint regardless of baseline FI compared to ICD alone (interaction p = 0.17). CRT-D upgrade led to a 0.03-point greater reduction in the mean FI change compared to the ICD arm (mean FI difference at 12-month - 0.03; 95% CI - 0.04 to - 0.01; p = 0.005). In this highly comorbid cohort, frailty was common but it did not diminish the clinical benefit of CRT-D upgrade. CRT-D upgrade decreased the risk of the primary endpoint regardless of baseline frailty status and led to a significant decrease in mean FI change compared to ICD alone.
Kuthi et al. (Thu,) conducted a rct in Heart failure with reduced ejection fraction (HFrEF) (n=360). CRT-D upgrade vs. ICD alone was evaluated on Composite of all-cause mortality, HF-hospitalization, or < 15% reduction of left ventricular end-systolic volume at 12 months (high-frailty burden group) (OR 0.08, 95% CI 0.04 to 0.19, p=< 0.001). CRT-D upgrade significantly decreased the risk of the primary composite endpoint regardless of baseline frailty status and led to a significant 0.03-point greater reduction in mean Frailty Index compared to ICD alone.