A patient with progressive dyspnea (shortness of breath) and paroxysmal nocturnal dyspnea (sudden shortness of breath at night) presents with echocardiogram findings of hypokinesia (reduced movement) of the anterior wall and a significantly reduced Left Ventricular Ejection Fraction (LVEF) of 30%, what is the next best investigation?

Coronary Angiography is the Next Best Investigation

In a patient presenting with progressive dyspnea, paroxysmal nocturnal dyspnea, anterior wall hypokinesia, and severely reduced LVEF of 30%, coronary angiography is the next best investigation to determine if ischemic heart disease is the underlying etiology and whether revascularization can improve outcomes. 1, 2

Rationale for Coronary Angiography

The clinical presentation strongly suggests new-onset heart failure with reduced ejection fraction (HFrEF), and the anterior wall hypokinesia is a critical finding that points toward a potential ischemic etiology involving the left anterior descending artery territory. 1, 2

Guideline-Based Recommendations

• ACC/AHA guidelines (Class I recommendation) state that coronary arteriography should be performed in patients presenting with heart failure who have angina or significant ischemia unless the patient is not eligible for revascularization. 1

• Even without angina, coronary angiography is reasonable (Class IIa) for patients presenting with heart failure who have known or suspected coronary artery disease, as this patient does with regional wall motion abnormalities. 1

• The combination of anterior wall hypokinesia and severely reduced ejection fraction (30%) suggests significant myocardium at risk that may benefit from urgent revascularization to prevent further deterioration and improve survival. 2

Why Coronary Angiography Takes Priority

The anterior wall hypokinesia is a regional wall motion abnormality that strongly suggests coronary artery disease as the underlying cause rather than a non-ischemic dilated cardiomyopathy (which would typically show global hypokinesis). 1

• Invasive catheter coronary angiography remains the clinical gold standard to diagnose coronary artery disease and is essential for guiding revascularization decisions. 2

• Identifying ischemic heart disease is critical because coronary revascularization in appropriate patients can improve mortality, prevent further myocardial damage, and potentially improve left ventricular function if viable myocardium is present. 2

Why Other Options Are Inappropriate

Myocardial Perfusion Imaging (Option A)

• Functional testing such as myocardial perfusion imaging is reserved for stable patients or those with equivocal findings, not for patients with clear evidence of severe left ventricular dysfunction and regional wall motion abnormalities requiring urgent evaluation. 2
• This would delay definitive diagnosis and treatment. 2

CT Coronary Angiography (Option B)

• CT coronary angiography is not appropriate for acute heart failure management with severe LV dysfunction; it is used for stable chest pain evaluation or when ischemia needs to be excluded in lower-risk patients. 2
• When there is already echocardiographic evidence of significant cardiac dysfunction with regional wall motion abnormalities, invasive angiography is needed for both diagnosis and potential immediate intervention. 2

Chest X-Ray (Option D)

• Chest radiography does not address the underlying coronary pathology requiring urgent intervention and provides no information about coronary anatomy or revascularization options. 2
• While chest x-ray may show cardiomegaly or pulmonary congestion, it does not change management in this scenario where the diagnosis of heart failure is already established by echocardiography. 1

Clinical Pathway

After coronary angiography establishes whether the etiology is ischemic or non-ischemic:

• If significant coronary disease is found, revascularization (PCI or CABG) should be considered based on anatomy and viability assessment. 1

• Regardless of findings, guideline-directed medical therapy for HFrEF should be initiated, including ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists. 1

• Viability assessment (with stress echocardiography or cardiac MRI) may be performed subsequently if coronary disease is found to determine if non-contracting myocardium is viable and would benefit from revascularization. 1

Important Caveat

The only scenario where coronary angiography would not be appropriate is if the patient has comorbidities or frailty that make them ineligible for any form of revascularization. 1 However, this should not be assumed without careful assessment, as revascularization can significantly improve outcomes in ischemic cardiomyopathy. 1, 2