Coronary Angiography (Option C)
Coronary angiography is the next best investigation for this patient with anterior STEMI, severe LV dysfunction (EF 30%), and heart failure symptoms. This patient requires urgent evaluation for coronary revascularization to improve mortality and prevent further myocardial damage.
Rationale for Coronary Angiography
Invasive catheter coronary angiography remains the clinical gold standard to diagnose coronary artery disease and is essential for guiding revascularization decisions in acute coronary syndromes 1.
The presence of anterior STEMI on ECG with corresponding anterior wall hypokinesia and severely reduced ejection fraction (30%) indicates acute ischemic injury requiring definitive anatomic assessment of the coronary arteries 1.
Coronary angiography in patients with marked limitation of ordinary activity despite maximal medical therapy is indicated according to ACC/AHA guidelines, and this patient's paroxysmal nocturnal dyspnea represents severe functional impairment 1.
Why Other Options Are Inappropriate
Myocardial Perfusion Imaging (Option A)
- Stress testing (including myocardial perfusion) is contraindicated in acute STEMI and would delay definitive treatment 1.
- Functional testing is reserved for stable patients or those with equivocal findings, not acute coronary syndromes with clear ECG evidence of infarction 1.
CT Coronary Angiography (Option B)
- While CCTA has excellent ability to rule out coronary stenosis in low- and intermediate-risk populations, it is not appropriate for acute STEMI management 1.
- CCTA is used for stable chest pain evaluation or when ischemia needs to be excluded, not when STEMI is already diagnosed 1, 2.
Chest X-ray (Option D)
- Chest radiography is useful for assessing pulmonary congestion in heart failure but does not address the underlying coronary pathology requiring urgent intervention 1.
- While it may show pulmonary edema, it provides no information about coronary anatomy or revascularization options 1.
Clinical Implications
Coronary revascularization is indicated when prognostically relevant ischemia is diagnosed, and anterior STEMI with severe LV dysfunction represents high-risk anatomy requiring intervention 3.
The combination of anterior wall hypokinesia and severely reduced ejection fraction suggests significant myocardium at risk that may benefit from urgent revascularization to prevent further deterioration and improve survival 1.
Critical Pitfall to Avoid
Do not delay invasive coronary angiography by performing non-invasive testing in a patient with clear ECG evidence of STEMI. The ECG showing anterior STEMI has already established the diagnosis of acute coronary syndrome, and the patient requires catheterization for potential percutaneous coronary intervention or surgical revascularization 1.