A 65 year old woman with ischaemic cardiomyopathy and LVEF 30% comes for review in the outpatient clinic. She is NYHA class II and has been optimally revascularized. Her current heart failure medications are bisoprolol 10 mg od, ramipril 10 mg od, ivabradine 7.5 mg bd, and spironolactone 25 mg. Her ECG shows sinus rhythm, left bundle branch block (QRS duration 135 ms), left axis deviation, and PR interval 180 ms.
Which one of the following managements would you recommend next?A. Refer for transplant assessment
This is difficult as the 2012 ESC Guidelines and NICE Guidelines differ. The patient remains in NYHA class II despite optimal medication and an ECG shows sinus rhythm and LBBB. The ESC recommends CRT-D in patients in sinus rhythm with a QRS duration of ≥130 ms, LBBB QRS morphology, and an EF ≤30%. If she was in NYHA class III (or class IV with reasonable functionality), then CRT-P/D (defibrillators may be less desirable in advanced HF) is recommended for patients with a QRS ≥120 ms (LBBB) and an EF ≤35%, who are expected to survive with good functional status for >1 year. The ESC does not recommend dyssynchrony echo assessment. Currently NICE recommends CRT for more advanced heart failure (NHYA class III–IV) with EF <35%, and distinguishes the need for a defibrillator based on cardiomyopathy of ischaemic origin. A QRS duration of 120–150 ms requires dyssynchrony on echo. The patient’s age is against transplant.