A 55-year-old woman with nonischemic dilated cardiomyopathy and exertional dyspnea (New York Heart Association [NYHA] functional class III) and 2-pillow orthopnea underwent placement of an implantable...

A 55-year-old woman with nonischemic dilated cardiomyopathy and exertional dyspnea (New York Heart Association [NYHA] functional class III) and 2-pillow orthopnea underwent placement of an implantable cardioverter-defi brillator 4 years ago for sudden cardiac arrest prophylaxis. Now she returns and asks whether cardiac resynchronization therapy may be appropriate. Her current medications are lisinopril 5 mg daily, carvedilol 6.25 mg twice daily, spironolactone 25 mg daily, and furosemide 40 mg daily. Physical examination and diagnostic study fi ndings were as follows: heart rate 97 beats per minute, blood pressure 142/70 mm Hg, jugular venous pressure 12 cm water, lungs clear, lateral displacement of the cardiac impulse, audible third heart sound, and no murmurs; electrocardiography showed left bundle branch block (LBBB) with QRS duration of 130 ms, and transthoracic echocardiography showed left ventricular ejection fraction (LVEF) of 20%. What is the most appropriate management for this patient at this point? a. Th ere is no indication for cardiac resynchronization therapy (CRT)—the symptoms are not severe enough. b. Th ere is no indication for CRT—the QRS complex is not wide enough. c. Upgrade to CRT now. d. Up-titrate the dosages of lisinopril and carvedilol