Advances in the management of heart failure: beyond the four pillars?

Myocardial dysfunction & atrial disorders Course resource

20 March 2026

This iHF session, features Christophe Leclercq, Shelley Zieroth, Alexandre Mebazaa, Gianluigi Savarese and Biykem Bozkurt, who discuss the integration of cardiac rhythm management devices alongside GDMT in HFrEF. They cover residual sudden cardiac death risk under contemporary pharmacological therapy, phenotype-driven referral timing for ICD and CRT, and the DirectHF consensus, a global peer-to-peer program to implement guideline-directed cardiac rhythm management device therapy in heart failure.

Persistent residual risk despite GDMT

Heart failure remains a global pandemic affecting over 60 million people worldwide. Despite the four-pillar pharmacological framework, sudden cardiac death still accounts for 35–39% of all-cause mortality in contemporary heart failure trials, with an annualised residual risk of approximately 2.5–3.75% per 100 patient-years. Recent large-scale non-randomised studies confirm that ICD therapy reduces all-cause mortality by 12–32% in patients with HFrEF treated with contemporary GDMT.

Rethinking the timing of device referral

A key focus of this iHF 2026 session is the integration of ICDs and CRT within GDMT, not as competing strategies, but as complementary interventions. Experts challenged two clinical misconceptions: that pharmacological optimisation should always precede device referral, and that modern GDMT has made ICD redundant. A phenotype-driven approach to referral and device implantation is recommended, with a particular attention to choosing the right device for the right patient:

Immediate referral in patients at high risk for ventricular arrythmias and sudden cardiac death or very low EF unlikely to recover with pharmacological treatment
Early referral (within or before three months) in patients with wide LBBB, where delayed CRT implantation is associated with higher cardiovascular mortality and HF hospitalisation
CRT as an enabler of GDMT up-titration in patients with intolerance to target doses

Optimising the management of heart failure goes beyond pharmacological therapy. GDMT encompasses both drug and device therapy, and the two are complementary, not competing. A phenotype-driven, patient-centred approach should guide clinicians toward earlier, more individualised device referral decisions.

Sponsored by Medtronic