What is the best next step for a patient with increasing paroxysmal nocturnal dyspnea, echocardiogram showing hypokinesia of the right wall and reduced ejection fraction, and no obvious STEMI (ST-Elevation Myocardial Infarction) on ECG (Electrocardiogram)?

Coronary Angiography for Suspected Ischemic Cardiomyopathy

This patient requires invasive coronary angiography (Option C) as the next step. The combination of progressive heart failure symptoms, severely reduced ejection fraction (30%), and regional wall motion abnormality (right wall hypokinesia) indicates high probability of underlying coronary artery disease requiring definitive diagnosis and potential revascularization 1.

Rationale for Invasive Coronary Angiography

Coronary angiography is the gold standard for patients with new-onset heart failure and reduced ejection fraction when ischemic etiology is suspected 1. This patient's presentation strongly suggests ischemic cardiomyopathy:

• Regional wall motion abnormality (right wall hypokinesia) is highly specific for coronary disease rather than non-ischemic dilated cardiomyopathy, which typically shows global hypokinesis 1
• Progressive paroxysmal nocturnal dyspnea with severely reduced EF (30%) represents high-risk acute coronary syndrome without ST elevation 1
• The absence of obvious STEMI on ECG does not exclude acute coronary occlusion or critical stenosis requiring urgent intervention 1

Why Not CT Coronary Angiography (Option B)?

CT coronary angiography has significant limitations in this clinical scenario:

• CT cannot provide immediate therapeutic intervention if critical stenosis or acute occlusion is identified 2
• Blooming artifacts from calcium and inferior temporal resolution make CT less reliable for definitive diagnosis in symptomatic patients 2
• Patients with acute coronary syndromes require invasive assessment for potential immediate revascularization 1

Why Not Myocardial Perfusion Scan (Option A)?

Stress testing is contraindicated and inappropriate:

• Patients with decompensated heart failure (PND, EF 30%) should not undergo stress testing due to high risk of hemodynamic deterioration 1
• Functional testing delays definitive diagnosis when invasive angiography is already indicated 1
• Regional wall motion abnormality with reduced EF already establishes high pretest probability of significant coronary disease 1

Clinical Decision Algorithm

For patients presenting with new heart failure and reduced ejection fraction:

1. If regional wall motion abnormality present → proceed directly to coronary angiography 1
2. If hemodynamically unstable or ongoing ischemic symptoms → emergency angiography 1
3. If electrically unstable (arrhythmias) → urgent angiography 1

This patient meets criteria for urgent coronary angiography based on:

• Severely reduced EF (30%) with progressive symptoms 1
• Regional wall motion abnormality suggesting coronary territory involvement 1
• High probability of revascularizable disease affecting mortality and quality of life 1

Expected Management Following Angiography

If obstructive coronary disease is identified:

• Percutaneous coronary intervention for culprit lesions improves outcomes in ischemic cardiomyopathy 1
• Complete revascularization should be considered for multivessel disease with viable myocardium 1
• Guideline-directed medical therapy including beta-blockers, ACE inhibitors, and aldosterone antagonists 1

If non-obstructive coronary arteries are found:

• Diagnosis shifts to non-ischemic cardiomyopathy requiring alternative workup 1
• Consider cardiac MRI to evaluate for myocarditis, infiltrative disease, or other etiologies 1
• Initiate heart failure therapy with reassessment of EF in 3 months for ICD consideration 1

Critical Pitfalls to Avoid

• Do not delay angiography waiting for troponin results or stress testing in patients with new heart failure and regional wall motion abnormalities 1, 3
• Do not assume non-ischemic etiology based on absence of chest pain - elderly patients and those with heart failure frequently present with atypical symptoms 4
• Do not perform stress testing in decompensated heart failure - this increases risk without providing actionable information when angiography is already indicated 1