A 35-year-old man with dilated cardiomyopathy (LVEF 28%) is on optimal medical therapy (sacubitril/valsartan, carvedilol, spironolactone, dapagliflozin). After 3 months, LVEF remains ≤35% with LBBB morphology and QRS ≥150 ms. What additional device therapy should be considered?

• A Implantable cardioverter-defibrillator (ICD) alone for sudden death prevention
• B Cardiac resynchronisation therapy with defibrillator function (CRT-D) ✓
• C Left ventricular assist device (LVAD) as destination therapy
• D Catheter ablation of the left bundle branch to restore synchrony

Explanation

CRT-D (cardiac resynchronisation therapy with defibrillator) has a Class I indication in HFrEF (LVEF ≤35%) with LBBB morphology and QRS ≥150 ms on optimal medical therapy (CARE-HF, MADIT-CRT, RAFT trials). CRT reduces HF hospitalisation, improves LVEF, and reduces mortality. The LBBB with broad QRS represents dyssynchrony that CRT corrects by resynchronising ventricular contraction. ICD alone does not correct mechanical dyssynchrony.

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

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Written and medically reviewed by the StethoPrep medical team.