A 55-year-old man with HFrEF (EF 28%) on optimal beta-blocker and ACE inhibitor therapy has NYHA class III symptoms, sinus rhythm, QRS 158 ms with LBBB morphology. Which device therapy offers the greatest survival benefit?

• A ICD only
• B CRT-P (cardiac resynchronisation therapy, pacemaker only)
• C CRT-D (cardiac resynchronisation therapy with defibrillator) ✓
• D Wearable cardioverter-defibrillator (WCD)

Explanation

CRT-D is the recommended device for patients with HFrEF (EF ≤35%), NYHA class II–III, sinus rhythm, LBBB with QRS ≥150 ms (Class I indication per ESC 2021/AHA ACC 2022 guidelines). CARE-HF and COMPANION trials demonstrated CRT significantly reduces mortality and hospitalizations. CRT-D (combining CRT with ICD) offers the added benefit of preventing sudden cardiac death compared to CRT-P alone and is preferred in patients with expected survival >1 year and no contraindications. LBBB morphology with QRS ≥150 ms confers maximal CRT benefit.

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

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Written and medically reviewed by the StethoPrep medical team.