From the Guidelines
Stable angina with a new decrease in Left Ventricular (LV) function, indicating impaired left ventricular function, requires thorough investigation.
Indicated Investigations
- Echocardiography to assess ventricular function and structure, including the evaluation of left ventricular hypertrophy (LVH) and diastolic dysfunction, especially in patients with hypertension or diabetes 1.
- Stress testing, such as exercise ECG, stress echo, or myocardial perfusion scintigraphy, to confirm the diagnosis, assess the severity of coronary heart disease, and evaluate the extent and localization of myocardial ischemia 1.
- Myocardial perfusion scintigraphy to demonstrate the extent and localization of myocardial ischemia and assess the risk of cardiac events 1.
- Computed Tomography Angiography (CTA) or invasive coronary angiography in patients with high clinical likelihood of obstructive coronary artery disease, severe symptoms refractory to medical therapy, or LV dysfunction suggestive of CAD 1.
Rationale
The choice of investigation depends on the patient's clinical likelihood of obstructive coronary artery disease, symptoms, and local expertise and availability 1. Echocardiography is particularly useful in evaluating ventricular function and identifying LVH and diastolic dysfunction, which are more prevalent in patients with hypertension or diabetes 1. Stress testing provides valuable information on the severity of coronary heart disease and the risk of cardiac events 1. Invasive investigations, such as coronary angiography, are recommended for patients with high-risk features, such as significant left main coronary artery stenosis, left main equivalent, or 3-vessel disease 1. The risks and benefits of each diagnostic test should be weighed against each other, taking into account the patient's individual characteristics and clinical presentation 1.
From the Research
Investigations for Stable Angina with Decreased Left Ventricular Function
The following investigations are indicated for stable angina with a new decrease in Left Ventricular (LV) function:
- Echocardiography to assess left ventricular systolic and diastolic function 2, 3, 4
- Cardiopulmonary exercise testing to evaluate peak oxygen consumption (VO2peak) 2
- Biochemical tests, such as B-type natriuretic peptide (NT-proBNP) and C-reactive protein (hsCRP) 2
- Nuclear device assessment of left ventricular ejection fraction (EF) at rest 5
- Doppler and tissue Doppler imaging (TDI) to measure left ventricular filling velocities, E/A ratio, deceleration time (DT) of E, isovolumic relaxation time (IVRT), and E/E ratio 3, 4
Revascularization Options
For patients with stable coronary artery disease (CAD) and left ventricular dysfunction, revascularization options include:
- Coronary artery bypass grafting (CABG) 6
- Percutaneous coronary intervention (PCI) 6
- Combined hybrid revascularization techniques 6
Medical Therapy
Medical therapy, such as ranolazine, amlodipine, and lacidipine, can also be used to improve left ventricular diastolic and systolic function in patients with stable angina and decreased LV function 3, 4