The Question
A 72-year-old man with ischemic cardiomyopathy, left ventricular ejection fraction of 28%, and New York Heart Association class II symptoms despite guideline-directed medical therapy is seen for follow-up. He had a myocardial infarction 8 months ago. ECG shows sinus rhythm with left bundle branch block and QRS duration of 162 ms. He has had no sustained ventricular arrhythmias or syncope. Blood pressure is 118/70 mm Hg, and creatinine is normal. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
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View on AmazonThe Correct Answer
D
Explanation
Clinical Pearl:
In patients with symptomatic HFrEF, left ventricular ejection fraction of 35% or less, sinus rhythm, left bundle branch block, and QRS 150 ms or greater despite optimal medical therapy, cardiac resynchronization therapy improves symptoms and survival. When ischemic cardiomyopathy is present and ejection fraction remains 35% or less, adding defibrillator capability is generally indicated for primary prevention.
Explanation:
This patient has clear guideline-based indications for cardiac resynchronization because he has symptomatic HFrEF, ejection fraction below 35%, sinus rhythm, and left bundle branch block with a markedly prolonged QRS. Because his cardiomyopathy is ischemic and he is more than 40 days out from myocardial infarction with persistent severe systolic dysfunction, primary prevention ICD therapy is also indicated, making CRT-D the best choice. A single-chamber pacemaker does not address ventricular dyssynchrony and could worsen heart failure by increasing right ventricular pacing. Amiodarone does not provide the survival benefit of an ICD for primary prevention in this setting. Observation alone is inappropriate because he already meets strong criteria for device therapy. Catheter ablation is used for selected tachyarrhythmias, not as treatment for standard left bundle branch block in a patient whose major issue is dyssynchronous HFrEF.
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