A 60-year-old man with HFrEF (EF 30%) on optimal medical therapy (ACEi, beta-blocker, MRA, SGLT2i) has NYHA Class III symptoms, QRS 165 ms with LBBB, sinus rhythm, and HR 72 bpm. Which device-based therapy is indicated?

• A Implantable cardioverter-defibrillator (ICD) alone
• B Left ventricular assist device (LVAD)
• C Cardiac resynchronization therapy without defibrillator (CRT-P) — ICD not needed as EF >25%
• D Cardiac resynchronization therapy with defibrillator (CRT-D) ✓

Explanation

CRT-D is indicated (Class I, Level A) in HFrEF patients with NYHA Class II-III, QRS ≥130 ms (especially with LBBB morphology), and sinus rhythm after ≥3 months of optimal medical therapy. LBBB with QRS ≥150 ms gives the greatest benefit. CRT improves EF, reduces HF hospitalizations, and reduces mortality. An ICD component is also warranted given EF 30% and ischemic/non-ischemic cardiomyopathy for primary prevention of SCD. LVAD is for end-stage refractory disease.

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

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Written and medically reviewed by the StethoPrep medical team.