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CRT upgrading from a previous device is common across ESC countries

Heart Failure

Cecilia Linde.jpgProf. Cecilia Linde

Upgrading patients with a pacemaker or implantable cardioverter-defibrillator (ICD) to cardiac resynchronisation therapy (CRT) is still widely practised across ESC member countries despite there being no trial evidence for its benefit compared with no upgrading, Professor Cecilia Linde (Karolinska University Hospital, Stockholm, Sweden) reported in a late-breaking trial presentation yesterday (LBT8).

Prof. Linde describes the rationale behind the current CRT Survey II.1 “In 2008–2009, a joint initiative between the ESC sister associations, HFA and the European Heart Rhythm Association, investigated how CRT was utilised within Europe.2 The study included over 2,400 patients from 13 countries, mainly within Western Europe. We found that 26% of patients receiving CRT had previously been implanted with a pacemaker or ICD.” CRT Survey II was conducted to give a picture of the situation 10 years on. “This time,” says Prof. Linde, “we wanted to include a greater number of countries to increase our knowledge of CRT utilisation over a wider region. CRT Survey II included 42 ESC countries over a broad geographic area, including Eastern Europe and North Africa. Information on over 11,000 patients was obtained mainly from university and teaching hospitals, with some contribution from smaller centres.” The findings for upgrading were remarkably similar to those recorded a decade ago.

“A quarter of patients (23.2%) were upgraded from either a previous pacemaker (61%) or a previous ICD (40%) and 76.8% had de novo implantation.”

“The patients undergoing upgrading were on average five years older than those receiving de novo implantation and tended to be in poorer health,” Prof. Linde explains. “They more commonly showed ischaemic aetiology and atrial fibrillation, had more comorbidities and worse renal function and were more likely to be pacemaker-dependent. In addition, their heart failure disease state was worse than that of de novo patients, with higher New York Heart Association class and NTproBNP values.” In terms of outcome, “the success rate of implantation was similar for de novo and upgrading implantations,” Prof. Linde says, “and, even though the upgraded patients were sicker before undergoing the procedure, there was no difference between the groups in the duration of hospitalisation and the incidence of complications.” However, at discharge, upgraded patients tended to be receiving less optimal medication. “We’re not really sure why this is,” she says, “but it could reflect their relatively poorer clinical condition; it is possible that doctors are particularly cautious with medications for patients who may be less able to tolerate them, or—and I believe this to be the predominant reason—it might be that this patient population is more likely to be overlooked.”

Although the 2016 ESC Guidelines3 for heart failure give only a grade IIb recommendation for consideration of CRT upgrading from a pacemaker or ICD—and then only in patients with heart failure and reduced ejection fraction (HFrEF), whose condition worsens despite optimum medical therapy and who have a high proportion of right ventricular pacing—the group were not totally surprised by the extent of CRT upgrading revealed by CRT Survey II. “Since the previous survey, it has become firmly established that right ventricular pacing may induce heart failure and it is possible that clinicians perform CRT implantation to avoid this eventuality. This is a perfectly sound scientific rationale,” Prof. Linde continues, “but we still have no clinical trial evidence to confirm if this approach is or is not beneficial.” This should soon be rectified. “The ongoing prospective, randomised, multicentre BUDAPEST CRT Upgrade study4 is comparing CRT-defibrillator upgrading with upgrading to ICD only in patients with intermittent or permanent right ventricular pacing and symptomatic HFrEF,” says Prof. Linde. “Hopefully this will give us a definitive answer regarding the value of CRT upgrading.”


1. Dickstein K, et al. Eur J Heart Fail 2018:Feb 19.Epub ahead of print.

2. Dickstein K, et al. Eur Heart J 2009;30:2450–2460.

3. Ponikowski P, et al. Eur Heart J 2016;37:2129–2200.

4. Merkely B, et al. Europace 2017;19:1549­­–1555.