A 58-year-old man with HFrEF (LVEF 28%) on maximally tolerated doses of ACEi + carvedilol + spironolactone has NYHA class III symptoms, QRS duration 158 ms (LBBB morphology), sinus rhythm, and LVEF remains 28% despite 3 months of optimal therapy. According to ESC 2021 guidelines, the device therapy with Level of Evidence A for this patient is:

• A Implantable cardioverter defibrillator (ICD) only
• B Cardiac contractility modulation (CCM)
• C Cardiac resynchronization therapy with defibrillator (CRT-D) ✓
• D Left ventricular assist device (LVAD)

Explanation

CRT-D (cardiac resynchronization therapy with ICD function) has Class I, Level A indication in symptomatic HFrEF (LVEF ≤35%, NYHA II–IV) with sinus rhythm, LBBB morphology, and QRS duration ≥150 ms (or ≥130 ms with typical LBBB). This patient fulfills all criteria: LVEF 28%, QRS 158 ms LBBB, NYHA III sinus rhythm. CARE-HF and COMPANION trials demonstrated CRT reduces mortality, HF hospitalizations, and reverses cardiac remodeling. ICD alone without CRT would miss the hemodynamic benefit of resynchronization. LVAD is for end-stage/refractory HF. CCM is investigational for narrow QRS HF.

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

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Written and medically reviewed by the StethoPrep medical team.