A 66-year-old man with HFrEF (EF 28%) is optimised on maximally tolerated doses of sacubitril/valsartan, bisoprolol, spironolactone, and dapagliflozin. He remains in NYHA Class III with LBBB (QRS 162 ms) on ECG. What intervention has the strongest evidence for further reducing mortality and morbidity?

• A Implantable loop recorder
• B IV iron infusion for iron deficiency
• C High-dose furosemide to achieve euvolemia
• D Cardiac resynchronisation therapy (CRT) ✓

Explanation

CRT (biventricular pacing) is indicated in HFrEF (EF ≤35%) with sinus rhythm, LBBB morphology, and QRS ≥150 ms (Class I indication per ESC 2021 guidelines), or LBBB with QRS 130–149 ms (Class IIa). This patient with QRS 162 ms and LBBB fulfils Class I criteria for CRT, which has demonstrated significant reductions in mortality, HF hospitalisations, and improvement in EF and NYHA class (CARE-HF, COMPANION trials). With optimal GDMT already on board, CRT is the next most impactful intervention.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.