Long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control in select patients with stage D HF despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation (280 282). (Level of Evidence: B) Table 17. Recommendations for Device Therapy for Management of Stage C HF Recommendations COR LOE References 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 y* I A 148,249 CRT is indicated for patients who have LVEF 35%, sinus rhythm, and LBBB with a QRS 150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT I A (NYHA class III/IV) B (NYHA class II) 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 y* I B 255 257 CRT can be useful for patients who have LVEF 35%, sinus rhythm, a non-LBBB pattern with a QRS 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT IIa A 250 252,254 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 GDMT IIa B 250 254,258 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 CRT IIa B 259 264 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%) IIa C 261,265 267 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 comorbidities* IIb B 268 271 CRT may be considered for patients who have LVEF 35%, sinus rhythm, a non-LBBB pattern with QRS 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMT IIb B 254,272 CRT may be considered for patients who have LVEF 35%, sinus rhythm, a non-LBBB pattern with a QRS 150 ms, and NYHA class II symptoms on GDMT IIb B 253,254 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 IIb C 253,254 CRT is not recommended for patients with NYHA class I or II symptoms and a non-LBBB pattern with QRS <150 ms III: No Benefit B 253,254,272 CRT is not indicated for patients whose comorbidities and/or frailty limit survival to <1 y III: No Benefit C 37 *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. 