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Device Therapy Timeline in HF — EECC MCQ

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EasyHeart FailureDevice Therapy Timeline in HFEECC

A 60-year-old man with HFrEF asks about the optimal timing of device therapy in the HF management timeline. When should ICD and CRT be considered relative to GDMT initiation?

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Correct answer: E — GDMT should be initiated first and uptitrated over at least 3 months; LVEF is then reassessed — if LVEF remains ≤35% with QRS ≥130 ms, CRT should be considered; if LVEF ≤35% without CRT indication, ICD should be considered

The ESC 2023 HF Guidelines recommend a stepwise approach: (1) Start and uptitrate all four pillars of GDMT (ACEi/ARNI + beta-blocker + MRA + SGLT2i) simultaneously with close follow-up (STRONG-HF approach); (2) After ≥3 months of optimal GDMT, reassess LVEF; (3) If LVEF remains ≤35% and QRS ≥130 ms (especially ≥150 ms with LBBB), CRT-D is indicated; (4) If LVEF remains ≤35% without CRT indication (narrow QRS, non-LBBB pattern), primary prevention ICD is indicated. This sequence ensures that patients whose LVEF recovers above 35% with GDMT avoid unnecessary device implantation. During the GDMT optimisation period, a WCD may provide interim SCD protection if risk is high.

Reference: ESC (2023): HF Guidelines; ESC (2021): Pacing/CRT Guidelines