A 58-year-old man with HFrEF (EF 32%) is on optimal doses of carvedilol, sacubitril-valsartan and eplerenone. He has NYHA class II, sinus rhythm, HR 75 bpm, BP 110/70 mmHg. QRS duration is 158 ms with LBBB morphology. Which additional device or drug intervention has a Class I indication for mortality reduction in this patient?

• A Cardiac resynchronisation therapy with defibrillator (CRT-D) ✓
• B Implantable cardioverter-defibrillator (ICD) alone
• C Ivabradine (if HR ≥70 bpm in sinus rhythm)
• D Adding digoxin to current regimen

Explanation

Cardiac resynchronisation therapy (CRT) has a Class I indication in HFrEF (EF ≤35%) in sinus rhythm with LBBB morphology and QRS ≥150 ms (MADIT-CRT, RAFT, CARE-HF trials). CRT-D (combining CRT with ICD) is preferred over CRT-P in patients with expected survival >1 year to prevent sudden cardiac death. The patient has QRS 158 ms with LBBB — exactly the subgroup with the largest CRT benefit. Ivabradine (SHIFT trial) is indicated in HFrEF with HR ≥70 bpm in sinus rhythm despite maximum tolerated beta-blocker; here HR is 75 but the bigger indication is CRT. ICD alone would not correct dyssynchrony.

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

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Written and medically reviewed by the StethoPrep medical team.