A 55-year-old man with HFrEF (LVEF 32%) is on maximally tolerated doses of sacubitril/valsartan, carvedilol, and eplerenone. He remains NYHA Class III with persistent symptoms and LVEF 30% after 3 months of optimal medical therapy. His QRS duration is 165 ms with left bundle branch block morphology. Which device therapy has shown mortality benefit in this patient?
- A Cardiac resynchronisation therapy with defibrillator (CRT-D) ✓
- B Implantable cardioverter-defibrillator (ICD) alone
- C CRT-P (pacemaker only) as defibrillator function is not required in NYHA Class III
- D Left ventricular assist device (LVAD) as destination therapy
Explanation
CRT-D is indicated in HFrEF patients with LVEF ≤ 35%, NYHA Class II–III symptoms despite optimal medical therapy, sinus rhythm, and LBBB morphology with QRS ≥ 150 ms (strongest indication) or 130–149 ms with LBBB. This patient meets all criteria: LVEF 30%, NYHA III, QRS 165 ms with LBBB, on OMT. CRT reduces mortality by approximately 36% (COMPANION trial) and improves LVEF and symptoms through biventricular synchronisation. CRT-D is preferred over CRT-P when there is additional indication for ICD (primary prevention: LVEF ≤ 35%, ischaemic or non-ischaemic NYHA II–III on OMT ≥ 3 months). ICD alone does not address dyssynchrony or symptoms. LVAD is reserved for advanced/end-stage HF refractory to all therapies.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.