Upgrading right ventricular pacing to cardiac resynchronization in HFrEF patients with frailty
E D Merkel, L Kuthi, R Masszi, Z Szakacs, M Nemeth, B Veres, A Behon, Z S Kis, W Schwertner, A Kosztin, B MerkelyAbstract
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.