72-year-old man with dyspnea and QRS 164 ms
A 72-year-old man with ischemic cardiomyopathy, left ventricular ejection fraction 28%, and chronic left bundle branch block has worsening exertional dyspnea despite maximally tolerated sacubitril-valsartan, carvedilol, spironolactone, and empagliflozin. He has had no syncope or sustained ventricular arrhythmias. Blood pressure is 112/68 mm Hg, pulse 64/min. ECG shows sinus rhythm with QRS duration 164 ms and left bundle branch block morphology. Echocardiography confirms stable ejection fraction of 28%. He remains limited to walking one block before stopping. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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C
Explanation
Clinical Pearl:
In symptomatic HFrEF with LVEF 35% or less, sinus rhythm, left bundle branch block, and QRS 150 ms or greater despite guideline-directed medical therapy, cardiac resynchronization therapy improves symptoms and survival. In ischemic cardiomyopathy, defibrillator capability is generally added for primary prevention when standard criteria are met.
Explanation:
This patient has persistent symptomatic HFrEF with an ejection fraction below 35%, sinus rhythm, and a markedly prolonged QRS with left bundle branch block despite appropriate medical therapy, which is the classic setting for cardiac resynchronization therapy. Contemporary heart failure guidance supports CRT in this scenario because it improves ventricular synchrony, functional status, heart failure hospitalization, and mortality. A CRT device with defibrillator capability is the best choice here because his ischemic cardiomyopathy and low ejection fraction also meet primary prevention criteria for sudden death reduction. A single-chamber right ventricular pacemaker can worsen dyssynchrony and is not indicated without a bradyarrhythmia pacing need. Amiodarone does not replace indicated device therapy for primary prevention and does not provide the same survival benefit in this setting. Atrioventricular node ablation is used for refractory rate control in atrial fibrillation, which he does not have, and observation alone is inappropriate because he remains symptomatic with a strong device indication.
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