A 58-year-old man with HFrEF (LVEF 28%, NYHA III) is on optimized GDMT: sacubitril/valsartan 97/103 mg BD, carvedilol 25 mg BD, spironolactone 25 mg/day, and dapagliflozin 10 mg/day. QRS duration is 168 ms with LBBB morphology. The next intervention shown to further reduce mortality is:
- A Add ivabradine if heart rate ≥70 bpm
- B Implantable cardioverter defibrillator (ICD) alone
- C Cardiac resynchronization therapy with defibrillator (CRT-D) ✓
- D Increase sacubitril/valsartan to maximum tolerated dose
Correct answer: C. Cardiac resynchronization therapy with defibrillator (CRT-D)
Explanation
QRS duration ≥150 ms with LBBB morphology in a patient with LVEF ≤35% and NYHA class II–IV on optimized GDMT is a Class IA indication for CRT-D, which reduces all-cause mortality, HF hospitalization, and promotes reverse remodeling. CRT-D is superior to ICD alone in patients with LBBB QRS ≥150 ms (MADIT-CRT, RAFT trials). Ivabradine is indicated when heart rate ≥70 bpm in sinus rhythm on maximally tolerated beta-blocker — it reduces HF hospitalization but not mortality in the SHIFT trial. Sacubitril/valsartan titration has already been done.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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