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Pacing Strategy in HFrEF — EECC MCQ

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ModerateCardiac DevicesPacing Strategy in HFrEFEECC

A 70-year-old man with symptomatic complete heart block and HFrEF (LVEF 32%) requires permanent pacing. His QRS is narrow (100 ms) during ventricular escape. He is expected to require a high percentage of ventricular pacing. What pacing strategy is recommended to avoid pacing-induced cardiomyopathy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — CRT (or conduction system pacing) rather than conventional RV pacing, to maintain ventricular synchrony given the anticipated high pacing burden and pre-existing LV dysfunction

In patients requiring permanent pacing with a high anticipated pacing percentage (as in complete heart block) and pre-existing LV dysfunction, conventional RV apical pacing is detrimental — it induces electromechanical dyssynchrony that can worsen LV function (pacing-induced cardiomyopathy). The 2021 ESC Pacing Guidelines recommend CRT (biventricular pacing) or conduction system pacing (His bundle or left bundle branch area pacing) for patients with: (1) LVEF <50% and expected ventricular pacing >40%, or (2) AV block requiring pacing with an indication for CRT (LVEF ≤35%, NYHA II-IV). This patient's LVEF of 32% with anticipated 100% pacing makes CRT (or CSP) the appropriate choice.

Reference: ESC (2021): Guidelines on Cardiac Pacing and CRT