What's the next step if an echocardiogram (echo) shows hypokinetic wall motion abnormalities but a subsequent myocardial perfusion study is negative?

From the Guidelines

The next step when an echocardiogram shows hypokinetic wall motion abnormalities but a subsequent myocardial perfusion study is negative should be a comprehensive clinical evaluation by a cardiologist, potentially including further testing such as cardiac MRI or coronary CT angiography to resolve the diagnostic uncertainty. This approach is supported by the 2024 ESC guidelines for the management of chronic coronary syndromes, which emphasize the importance of combining clinical evaluation with imaging techniques for accurate diagnosis and management 1. The guidelines suggest that while echocardiography provides valuable information about cardiac function and anatomy, its findings should be interpreted in the context of the patient's overall clinical picture, including symptoms, risk factors, and results from other diagnostic tests.

When interpreting the results of an echocardiogram and a myocardial perfusion study, it's crucial to consider the potential reasons for the discrepancy, such as:

• The wall motion abnormality might represent an old, healed infarction with viable but dysfunctional myocardium.
• It could be due to non-ischemic cardiomyopathy.
• One of the tests might have produced a false result. The clinical context, including symptoms, risk factors, and ECG findings, is vital in determining the appropriate next steps and should guide the selection of additional testing to resolve this diagnostic uncertainty, as suggested by the guidelines 1.

Key considerations in the management of such patients include:

• Continuing any prescribed cardiac medications such as aspirin, statins, beta-blockers, or ACE inhibitors while awaiting further evaluation.
• Potentially proceeding with cardiac MRI with late gadolinium enhancement to assess for fibrosis or scarring.
• Evaluating coronary anatomy through coronary CT angiography.
• Considering invasive coronary angiography if there is a high clinical suspicion of coronary artery disease. These steps are in line with the recommendations for further investigation when initial tests yield discordant results, aiming to provide a definitive diagnosis and guide appropriate management 1.

From the Research

Next Steps After Negative Myocardial Perfusion Study

If an echocardiogram shows hypokinetic wall motion abnormalities but a subsequent myocardial perfusion study is negative, several considerations come into play:

• The presence of hypokinetic wall motion abnormalities on an echocardiogram can indicate various conditions, including coronary artery disease (CAD) or non-ischemic cardiomyopathy 2.
• A negative myocardial perfusion study suggests that there may not be significant ischemia or perfusion defects at the time of the study, but it does not entirely rule out CAD or other cardiac conditions 3.
• The sensitivity and specificity of myocardial perfusion imaging can be affected by several factors, including patient motion during the study and the presence of conditions like left ventricular dysfunction or cardiomyopathy 4.

Diagnostic Considerations

Given the initial findings and the negative myocardial perfusion study, the next steps might include:

• Further evaluation to determine the cause of the hypokinetic wall motion abnormalities, which could involve additional imaging studies, such as cardiac MRI, or invasive procedures like coronary angiography 2, 5.
• Assessment for other potential causes of wall motion abnormalities, such as cardiomyopathy, valvular disease, or non-cardiac conditions that could affect cardiac function 2, 6.
• Consideration of stress testing, potentially with different modalities (e.g., exercise stress test, dobutamine stress echocardiography), to evaluate for inducible ischemia or to further assess cardiac function under stress conditions 5, 6.

Management and Follow-Up

Management would depend on the underlying cause of the wall motion abnormalities and the results of any additional diagnostic tests:

• If CAD is suspected despite a negative myocardial perfusion study, consideration of coronary angiography may be warranted, especially if there are high-risk features or a strong clinical suspicion of CAD 3.
• For patients with non-ischemic cardiomyopathy or other conditions, management would focus on optimizing heart failure treatment and addressing any underlying causes or contributing factors 2.
• Close follow-up and periodic reassessment may be necessary to monitor for changes in cardiac function or the development of new symptoms 3, 6.