What is the next best investigation for a patient with progressive dyspnea, paroxysmal nocturnal dyspnea, hypokinesia of the anterior wall, and a significantly reduced left ventricle ejection fraction (LVEF) of 30%?

Next Best Investigation: Coronary Angiography

In a patient presenting with progressive dyspnea, paroxysmal nocturnal dyspnea, anterior wall hypokinesia, and severely reduced LVEF of 30%, coronary angiography (Option C) is the next best investigation. 1, 2

Rationale for Direct Coronary Angiography

The presence of regional wall motion abnormalities (anterior wall hypokinesia) in new-onset cardiomyopathy mandates defining coronary anatomy, as echocardiography alone is insufficient for management decisions. 1 The American College of Cardiology explicitly states that invasive catheter coronary angiography remains the clinical gold standard to diagnose coronary artery disease and is essential for guiding revascularization decisions in this clinical scenario. 1, 2

Why Regional Wall Motion Abnormalities Matter

• Anterior wall hypokinesia with severely reduced LVEF represents a regional wall motion abnormality that strongly suggests coronary artery disease as the underlying etiology. 1
• Distinguishing ischemic from nonischemic cardiomyopathy is critical because patients with ischemic cardiomyopathy can have dramatic improvement with revascularization. 1
• 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

Symptomatic Severity Demands Urgent Evaluation

• The ACC/AHA guidelines indicate that coronary angiography is recommended for patients with marked limitation of ordinary activity, such as paroxysmal nocturnal dyspnea representing severe functional impairment. 1, 2
• The patient's progressive dyspnea and paroxysmal nocturnal dyspnea indicate NYHA class III-IV heart failure, which requires urgent diagnostic evaluation. 3

Why Not the Other Options

Option A: Myocardial Perfusion Imaging

• Do not delay definitive diagnosis with non-invasive stress testing in symptomatic patients with severe LV dysfunction and regional wall motion abnormalities. 1
• Non-invasive testing only postpones definitive diagnosis and potential life-saving intervention. 4
• Myocardial perfusion studies are contraindicated or provide limited diagnostic value in patients with severe LV dysfunction (LVEF 30%) and active heart failure symptoms. 5

Option B: CT Angiography

• While CT angiography can visualize coronary anatomy, it does not allow for immediate intervention or functional assessment with fractional flow reserve (FFR) if significant lesions are found. 5
• In symptomatic patients with severe LV dysfunction requiring urgent evaluation, invasive coronary angiography provides both diagnostic and therapeutic capability in a single procedure. 2

Option D: Chest X-ray

• Chest x-ray provides no information about coronary anatomy, myocardial viability, or revascularization potential, and is not a suitable alternative to coronary angiography for diagnosing coronary artery disease. 4
• While chest x-ray may show cardiomegaly and pulmonary congestion, it does not address the fundamental question of whether this is ischemic or nonischemic cardiomyopathy. 5

Clinical Management Algorithm

Immediate Steps

1. Proceed directly to coronary angiography without delay for non-invasive testing. 1
2. Optimize medical therapy with beta-blockers, ACE inhibitors/ARBs, statins, and antiplatelet agents while arranging angiography. 1, 2
3. Ensure diuretic therapy for symptom relief (dyspnea, paroxysmal nocturnal dyspnea). 5

Post-Angiography Management

• If coronary disease is identified with suitable anatomy for revascularization, proceed based on extent of disease and presence of viable myocardium. 1, 2
• If multivessel disease is found, viability assessment (with stress echocardiography or cardiac MRI) may be performed subsequently to determine if non-contracting myocardium is viable and would benefit from revascularization. 2
• Regardless of findings, guideline-directed medical therapy for HFrEF should be initiated, including ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists. 2
• Repeat echocardiography after revascularization and at follow-up to reassess ejection fraction for ICD candidacy if EF remains ≤35%. 1

Common Pitfalls to Avoid

• Do not assume nonischemic cardiomyopathy based solely on absence of chest pain or lack of obvious STEMI on ECG—anterior wall hypokinesia demands coronary evaluation. 1, 4
• Do not delay angiography to perform non-invasive testing first in symptomatic patients with regional wall motion abnormalities and severe LV dysfunction. 1
• Do not overlook that the ACC/AHA guidelines give a Class I recommendation for coronary arteriography in patients presenting with heart failure who have angina or significant ischemia. 2