A 50-year-old man with HFrEF (EF 30%) is on optimal guideline-directed medical therapy (GDMT): carvedilol, sacubitril-valsartan, spironolactone, and dapagliflozin. ECG shows sinus rhythm with LBBB (QRS duration 152 ms). LVEF remains 30% after 3 months. Which device intervention has a Class I recommendation in this scenario?

• A Implantable loop recorder
• B Cardiac resynchronisation therapy with defibrillator (CRT-D) ✓
• C Left ventricular assist device immediately
• D Prophylactic ICD without CRT

Explanation

CRT-D has a Class I recommendation (ESC/AHA guidelines) in patients with symptomatic HFrEF (LVEF ≤35%), sinus rhythm, LBBB morphology, and QRS duration ≥150 ms on optimised GDMT, as it reduces mortality, HF hospitalisation, and improves LV remodelling (CARE-HF, COMPANION trials). ICD alone without CRT is appropriate when LBBB QRS <150 ms or non-LBBB morphology. LVAD is reserved for advanced HF with inotrope dependence or cardiogenic shock. Implantable loop recorder is for arrhythmia diagnosis, not therapeutic intervention in this setting.

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

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Written and medically reviewed by the StethoPrep medical team.