Table 22

Recommendations for Device Therapy for Management of Stage C HF

RecommendationsCORLOEReferences
ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 d post-MI with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT, who are expected to live >1 yIA355,593
CRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMTIA (NYHA class III/IV)38,78,116,594
B (NYHA class II)595,596
ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 d post-MI with LVEF ≤30% and NYHA class I symptoms while receiving GDMT, who are expected to live >1 yIB362,597,598
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 GDMTIIaA78,116,594,596
CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMTIIaB78,116,594–596,599
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) AV nodal ablation or rate control allows near 100% ventricular pacing with CRTIIaB600–605
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%)IIaC155,602,606,607
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 comorbiditiesIIbB608–611
CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with a QRS duration of 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMTIIbB596,612
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 GDMTIIbB595,596
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 GDMTIIbC595,596
CRT is not recommended for patients with NYHA class I or II symptoms and non-LBBB pattern with QRS <150 msIII: No BenefitB595,596,612
CRT is not indicated for patients whose comorbidities and/or frailty limit survival to <1 yIII: No BenefitC38

AF indicates atrial fibrillation; AV, atrioventricular; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; LBBB, left bundle-branch block; LOE, Level of Evidence; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NYHA, New York Heart Association; and SCD, sudden cardiac death.

  • Counseling should be specific to each individual patient and should 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 (30).