What is the next step in managing a 61-year-old female with reduced EF, segmental hypokinesis, and evidence of ischemia on micro perfusion study?

Management of a 61-Year-Old Female with Reduced EF and Evidence of Ischemia

The next step in this patient should be coronary angiography to define the presence or absence of large-vessel coronary obstructions, as this will guide appropriate treatment decisions for her reduced ejection fraction and evidence of ischemia. 1

Rationale for Coronary Angiography

The patient presents with several concerning findings:

• Reduced ejection fraction (44%)
• Segmental wall motion abnormalities (hypokinetic interseptal wall, basal, and basal lateral segments)
• Evidence of ischemia on micro perfusion study

According to the ACC/AHA guidelines, coronary angiography is generally recommended in patients with heart failure and evidence of ischemia to define the presence or absence of large-vessel coronary obstructions 1. This is particularly important because:

1. Only coronary arteriography can reliably demonstrate or exclude the presence of obstructed coronary vessels 1
2. Perfusion deficits and segmental wall motion abnormalities (which this patient has) can be present in both ischemic and non-ischemic cardiomyopathy, making angiography necessary to definitively determine the etiology 1

Why Bypass Other Testing

While some providers might consider additional non-invasive testing, the guidelines specifically note that:

• Inhomogeneous nuclear images and abnormal wall-motion patterns are common in patients with non-ischemic cardiomyopathy 1
• The patient already has evidence of ischemia on micro perfusion study
• Proceeding directly to coronary angiography is appropriate in this scenario 1

Treatment Implications

The results of coronary angiography will determine the next steps in management:

1. If significant coronary artery disease is found:

   • Revascularization (PCI or CABG) may be considered, especially if there are large areas of viable myocardium 1
   • This could potentially improve left ventricular function 1

2. If no significant coronary disease is found:

   • Focus on optimal medical therapy for heart failure with reduced ejection fraction
   • This would include ACE inhibitors/ARBs, evidence-based beta-blockers, mineralocorticoid receptor antagonists, and possibly SGLT2 inhibitors 1
   • Evaluation for other causes of cardiomyopathy may be warranted 1

Additional Considerations

• Given the reduced EF of 44%, assessment for device therapy may be needed after optimization of medical therapy
• If the EF remains ≤35% despite optimal medical therapy for 3 months, evaluation for ICD or CRT may be indicated 1, 2
• High-intensity statin therapy should be initiated regardless of the angiography findings, as this patient has evidence of atherosclerotic cardiovascular disease 1, 3

Common Pitfalls to Avoid

1. Delaying definitive diagnosis: Relying solely on non-invasive testing when there are already signs of ischemia and reduced EF may delay appropriate treatment

2. Misinterpreting wall motion abnormalities: Wall motion abnormalities can occur in both ischemic and non-ischemic cardiomyopathy, making coronary angiography necessary for definitive diagnosis 1

3. Overlooking the need for comprehensive heart failure management: Regardless of the coronary findings, this patient will need optimization of guideline-directed medical therapy for her reduced EF 1

In summary, coronary angiography is the appropriate next step to definitively determine if coronary artery disease is the underlying cause of this patient's reduced ejection fraction and wall motion abnormalities, which will guide subsequent therapeutic decisions.