A 35-year-old man with HFrEF (LVEF 25%) and NYHA class III symptoms is on optimal GDMT. He is in normal sinus rhythm, HR 74 bpm, QRS duration 155 ms (LBBB morphology). Which device therapy is indicated?

• A CRT-D (cardiac resynchronization therapy with defibrillator) ✓
• B ICD alone (implantable cardioverter-defibrillator)
• C Wearable cardioverter-defibrillator for 90 days
• D Pacemaker for rate support only

Explanation

CRT-D is indicated (Class I, Level A) for symptomatic HFrEF (LVEF ≤35%) with LBBB morphology and QRS duration ≥150 ms (strongest benefit) or ≥130 ms, on optimal GDMT. CRT corrects electromechanical dyssynchrony, improving LVEF, symptoms, and reducing mortality and HF hospitalization (CARE-HF, COMPANION trials). An ICD alone does not provide resynchronization therapy. A wearable defibrillator is for newly diagnosed DCM or post-MI (first 40 days) before deciding on permanent ICD. A QRS ≥155 ms with LBBB provides the highest likelihood of CRT response.

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

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Written and medically reviewed by the StethoPrep medical team.