CRT-D or CRT-P: When There Is a Dilemma and How to Solve It

Cardiac resynchronization therapy (CRT) represents a cornerstone in the management of patients with heart failure and electrical dyssynchrony, improving symptoms, reducing hospitalizations, and prolonging survival. CRT can be delivered via a pacemaker (CRT-P) or an ICD (CRT-D). Despite its widespread use, the mortality benefit of CRT-D over CRT-P remains uncertain, as no head-to-head randomized trials have been designed to directly compare the two modalities, making device selection a frequent clinical dilemma. In practice, CRT-D accounts for 70–80% of CRT implantations in developed countries, yet solid evidence demonstrating its superiority over CRT-P is lacking. Specific patient groups, including those with non-ischemic cardiomyopathy, advanced age, multiple comorbidities, or limited life expectancy, may derive limited incremental benefit from CRT-D, which should be balanced against device costs and specific risks such as lead failure and inappropriate shocks. The present review aims to provide a comprehensive comparison between CRT-D and CRT-P, focusing on the existing body of evidence, criteria for patient selection, comparative clinical outcomes, and risk–benefit considerations for clinical decision-making.