A 55-year-old man has HFrEF (EF 28%) on maximally tolerated ARNI (sacubitril/valsartan), beta-blocker, and MRA. He remains NYHA Class III with BNP 1,200 pg/mL. His QRS is 155 ms with LBBB pattern. What is the next most evidence-based intervention?

• A Add digoxin to improve symptoms and reduce hospitalizations
• B Start ivabradine if resting heart rate >70 bpm
• C Refer for heart transplant evaluation immediately
• D Implant a cardiac resynchronization therapy defibrillator (CRT-D) ✓

Explanation

CRT-D is strongly indicated (Class I, ACC/AHA 2022) in HFrEF patients with EF ≤35%, NYHA Class II–III, QRS ≥150 ms with LBBB morphology on optimal medical therapy (OMT). The MADIT-CRT, RAFT, and CARE-HF trials demonstrated significant reductions in mortality, hospitalization, and reverse remodeling with CRT in this population. QRS ≥150 ms LBBB is the strongest predictor of CRT response. Ivabradine targets HR ≥70 bpm but is second-line after optimizing beta-blocker. Transplant is for refractory end-stage HF despite OMT and device therapy.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.