Should a 78-year-old female with severe heart failure, reduced left ventricular ejection fraction (LVEF) and symptoms of shortness of breath (SOB), elevated brain natriuretic peptide (BNP) and troponin levels, undergo heart catheterization to evaluate the aortic valve and coronary arteries for potential ischemia?

Should This Patient Undergo Heart Catheterization?

Yes, coronary angiography is reasonable in this 78-year-old woman with newly diagnosed severe HFrEF (LVEF 20-25%) to evaluate for ischemic etiology and assess revascularization options, despite flat troponins. 1

Rationale for Coronary Angiography

The ACC/AHA guidelines specifically recommend coronary angiography for patients presenting with heart failure who have chest pain that may or may not be of cardiac origin, have not had evaluation of their coronary anatomy, and have no contraindications to coronary revascularization (Class IIa). 1 Your patient had chest pain prior to admission that resolved spontaneously, making this recommendation directly applicable.

Key Supporting Evidence

• Coronary artery disease is a critical and potentially reversible cause of newly diagnosed heart failure, and registry data suggest that coronary angiography is underutilized in patients hospitalized with decompensated HF, leading to missed opportunities to diagnose important coronary disease. 1

• The ACC/AHA guidelines state that coronary angiography is reasonable for patients presenting with HF who have known or suspected coronary artery disease but who do not have angina, unless the patient is not eligible for revascularization of any kind (Class IIa). 1

• In patients with cardiogenic shock or severe decompensation, the ESC guidelines recommend rapid transfer to a tertiary care center with 24/7 cardiac catheterization services. 1

Why Flat Troponins Don't Rule Out Ischemic Etiology

• Many patients admitted with acute HF have low levels of detectable troponins not meeting criteria for an acute ischemic event but typical of chronic HF with acute exacerbation—this does not exclude underlying coronary disease as the cause of cardiomyopathy. 1

• Troponin elevation indicates acute myocardial injury, but chronic ischemic cardiomyopathy from prior infarctions or chronic ischemia may present with flat troponins. 1

• Your patient's troponin values (39,46) are essentially flat and do not suggest acute coronary syndrome, but this does not exclude significant coronary disease requiring revascularization. 1

The Aortic Valve Assessment

• Your echo shows AVA 1.2 cm² with mean gradient 5.4 mmHg and peak gradient 1.0 mmHg—these values do NOT indicate significant aortic stenosis. 2

• An AVA of 1.2 cm² is in the mild stenosis range (normal is >2.0 cm²), and the very low gradients (mean 5.4 mmHg) confirm this is not hemodynamically significant. 2

• The aortic valve is NOT the primary problem here and does not require intervention at this time. 2

Immediate Management Priorities

Continue Aggressive Medical Therapy

• While arranging catheterization, continue optimizing guideline-directed medical therapy (GDMT) for HFrEF, including ACE inhibitors or ARBs, beta-blockers, and mineralocorticoid receptor antagonists, as these are the cornerstone of disease-modifying therapy. 1, 3, 4

• Loop diuretics should be administered for symptomatic relief of congestion, with dose and duration adjusted according to symptoms and clinical status. 1, 2

• Monitor renal function and electrolytes closely during diuresis, especially potassium and magnesium. 2

Timing of Catheterization

• Coronary angiography should be performed relatively soon but does not require emergency timing given the flat troponins and resolved chest pain. 1

• The patient should be stabilized from a volume standpoint first, but catheterization should not be delayed for weeks while attempting medical optimization. 1, 2

Critical Clinical Pitfalls to Avoid

• Do not assume this is non-ischemic cardiomyopathy based solely on flat troponins—up to 70% of HFrEF cases have an ischemic etiology, and revascularization can improve outcomes in selected patients. 1

• Do not withhold or reduce beta-blocker therapy unless the patient has marked volume overload or was recently initiated on beta-blockers—continuation of beta-blockers in most hospitalized HF patients is well tolerated and results in better outcomes. 1

• Do not delay echocardiography or assume the diagnosis without objective evidence—you've appropriately obtained this already. 2

• Consider that the patient may have had a "silent" MI given the history of chest pain that resolved, and chronic ischemic cardiomyopathy may be the underlying etiology. 1

Additional Diagnostic Considerations

• The elevated BNP of 3118 pg/mL confirms significant cardiac dysfunction and volume overload, and patients with BNP >1,500 pg/mL have greater mortality and longer length of stay. 5

• Ensure a 12-lead ECG has been performed to assess for evidence of prior MI, Q waves, or conduction abnormalities that might suggest ischemic etiology. 2

• If coronary angiography reveals no significant coronary disease, consider other causes of cardiomyopathy including viral myocarditis, alcohol-induced cardiomyopathy, thyroid disease, or infiltrative diseases. 2