Heart Failure [ACCF/AHA]

Table 18. Recommendations for Device Therapy for Management of Stage C HF Recommendations COR LOE ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-MI with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT, who are expected to live >1 yeara CRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS duration of ≥150 ms, and NYHA class II, III, or ambulatory class IV symptoms on GDMT I A I ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-MI with LVEF ≤30% and NYHA class I symptoms while receiving GDMT, who are expected to live >1 yeara CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS ≥150 ms, and NYHA class III/ ambulatory class IV symptoms on GDMT CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS duration of 120–149 ms, and NYHA class II, III, or ambulatory class IV symptoms on GDMT CRT can be useful in patients with AF and LVEF ≤35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) atrioventricular nodal ablation or rate control allows near 100% ventricular pacing with CRT CRT can be useful for patients on GDMT who have LVEF ≤35% and are undergoing new or replacement device implantation with anticipated ventricular pacing (>40%) An ICD is of uncertain benefit to prolong meaningful survival in patients with a high risk of nonsudden death such as frequent hospitalizations, frailty, or severe comorbiditiesa CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS 120–149 ms, and NYHA class III/ambulatory class IV symptoms on GDMT CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS ≥150 ms, and NYHA class II symptoms on GDMT CRT may be considered for patients who have LVEF ≤30%, ischemic etiology of HF, sinus rhythm, LBBB with QRS ≥150 ms, and NYHA class I symptoms on GDMT I A (NYHA class III/ IV) B (NYHA class II) B IIa A IIa B IIa B IIa C IIb B IIb B IIb B IIb C CRT is NOT recommended for patients with NYHA class I or II symptoms and non-LBBB pattern with QRS <150 ms III: No Benefit B CRT is NOT indicated for patients whose comorbidities and/or frailty limit survival to <1 year III: No Benefit C a Counseling should be specific to each individual patient and include documentation of a discussion about the potential for sudden death and nonsudden death from HF or noncardiac conditions. Information should be provided about the efficacy, safety, and potential complications of an ICD and the potential for defibrillation to be inactivated if desired in the future, notably when a patient is approaching end of life. This will facilitate shared decision-making between patients, families, and the medical care team about ICDs. 31

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