Key result
CRT-D upgrade reduces frailty index vs ICD alone at 12 months in HFrEF.
Why the study?
Frailty and heart failure are increasingly prevalent and adversely affect prognosis, yet data regarding the potential frailty-modifying effect of CRT upgrade remain scarce.
Does CRT-D upgrade improve clinical outcomes and frailty in HFrEF patients with prior PM/ICD and ≥20% RV pacing burden compared to ICD alone?
RCT (n=360)
randomized
Does CRT-D upgrade improve clinical outcomes and frailty in HFrEF patients with prior PM/ICD and ≥20% RV pacing burden compared to ICD alone?
In a highly frail HFrEF population with high RV pacing burden, upgrading to CRT-D significantly improved the frailty index at 12 months compared to ICD alone.
Answers are grounded in this paper and cite their sources.
May warrant CRT-D upgrade for frailty reduction in paced HFrEF; extends outcome data despite neutral primary composite.
Background Frailty and heart failure (HF) both have become increasingly prevalent, particularly in the elderly and each adversely affects prognosis. Yet, data regarding the potential frailty-modifying effect of CRT upgrade remain scarce. Purpose The aim of this study was to investigate how frailty influences clinical outcomes, as well as the effect of CRT-D upgrade on subsequent frailty improvement, in the Budapest CRT Upgrade cohort. Methods Patients with heart failure and reduced ejection fraction (HFrEF) and an implanted pacemaker (PM) or implantable cardioverter-defibrillator (ICD) and ≥20% right ventricular (RV) pacing burden were randomized to receive either a CRT-D upgrade (n=215) or an ICD alone (n=145). Our primary composite endpoint was all-cause mortality, HF-hospitalization and or <15% reduction of LVESV from baseline to 12 months. the Using the original Rockwood method, we calculated frailty index (FI), patients with an FI score of ≤0.210 were categorized as non-frail, while those with higher scores were further classified into two frailty groups based on 0.1-point increments. Results At baseline, in the total cohort of 360 patients, frailty index was calculable with a mean of FI 0.39 ± 0.1, whereas at the 12-month it was assessable for 282 patients. A relevant number of patients showed high frailty, 272 (75.6%) categorized to Frail 2 group (FI ≥0.311), whereas 75 (20.8%) less frail patients grouped to Frail 1 (FI 0.211-0.310) and only 13 patients (3.6%) were non-frail (FI ≤0.210). Compared with patients in the non-frail group, those in Frail 1 or 2 did not have a significantly higher risk of the primary composite endpoint (Frail 1: unadjusted OR 1.79 [95% CI 0.45 to 7.23; p=0.41]; Frail 2: OR 2.1 [95% CI 0.56 to 7.92; p=0.27]). The mean FI change was significantly decreased in the CRT-D arm by a 0.02-point greater reduction compared to the ICD arm (mean FI difference at 12-month -0.02; 95% CI -0.37 to -0.005; p=0.012). Conclusions The Budapest CRT upgrade cohort represents a highly comorbid, vulnerable patient population. Even though more than 90% of the patients were frail to a certain extent, CRT-D upgrade led to a significant decrease in mean FI change.
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Merkel et al. (2026) conducted an RCT in Heart failure and reduced ejection fraction (HFrEF) (n=360). CRT-D upgrade vs. ICD alone was evaluated on All-cause mortality, HF-hospitalization and or <15% reduction of LVESV from baseline to 12 months. CRT-D upgrade significantly reduced the mean frailty index compared to ICD alone at 12 months (mean difference -0.02; 95% CI -0.37 to -0.005; P=0.012) in patients with HFrEF.
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