A 58-year-old man with HFrEF (LVEF 28%) is on maximally tolerated doses of ACEi, beta-blocker, and aldosterone antagonist. He remains NYHA class III with NT-proBNP of 2,400 pg/mL. QRS duration is 142 ms with LBBB morphology. Which additional device therapy has PROVEN mortality benefit?

• A Implantable loop recorder
• B Permanent pacemaker (right ventricular pacing)
• C Cardiac contractility modulation (CCM) device
• D Cardiac resynchronisation therapy with defibrillator (CRT-D) ✓

Explanation

CRT-D is indicated in HFrEF (LVEF ≤35%), NYHA class II-III, QRS ≥130 ms with LBBB morphology on optimal medical therapy. The CARE-HF and COMPANION trials demonstrated that CRT with defibrillation reduces mortality and hospitalisations significantly. QRS 142 ms with LBBB meets the strongest indication (Class I per ESC/ACC). Implantable loop recorder is diagnostic, not therapeutic. RV pacing paradoxically worsens dyssynchrony in LBBBs. CCM may improve symptoms but lacks mortality data.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.