What is the most appropriate next investigation for a patient presenting with progressive dyspnea (difficulty breathing) and paroxysmal nocturnal dyspnea (nighttime breathing difficulty), with echocardiography findings of hypokinesia (reduced movement) of the anterior wall and a significantly reduced left ventricular ejection fraction (LVEF) of 30%?

Coronary Angiography

The most appropriate next investigation is C. Coronary angiography, which is the clinical gold standard for definitively diagnosing coronary artery disease in patients with severely reduced LVEF, regional wall motion abnormalities, and heart failure symptoms. 1

Rationale for Invasive Coronary Angiography

The clinical presentation strongly suggests ischemic cardiomyopathy as the underlying etiology:

• Regional wall motion abnormality (anterior wall hypokinesia) indicates a regional rather than global dysfunction pattern, which is characteristic of ischemic rather than non-ischemic cardiomyopathy. 1

• The combination of severely reduced LVEF (30%), regional wall motion abnormality, and classic heart failure symptoms (progressive dyspnea and paroxysmal nocturnal dyspnea) makes ischemic cardiomyopathy the primary diagnostic consideration. 1

• Invasive catheter coronary angiography is explicitly recommended by the American College of Radiology as the most appropriate next investigation for this clinical scenario. 1

Why Not the Other Options

Myocardial Perfusion Imaging (Option A)

• Delaying definitive coronary assessment with non-invasive testing when regional wall motion abnormalities are already present on echocardiography can negatively impact patient outcomes, as time to revascularization matters in ischemic cardiomyopathy. 1

CT Coronary Angiography (Option B)

• CT coronary angiography has excellent sensitivity but relatively low specificity in high-risk patients, making it less appropriate when definitive diagnosis is needed for treatment decisions. 1
• This patient is already high-risk with severely reduced LVEF and regional wall motion abnormality, requiring definitive anatomic assessment rather than screening. 1

Chest X-ray (Option D)

• While chest radiography can identify cardiomegaly and pulmonary congestion, it does not provide the definitive coronary assessment needed to guide revascularization decisions. 2, 3
• Normal chest radiography does not exclude cardiac disease, particularly in established heart failure. 2, 3

Clinical Decision-Making Framework

Coronary angiography serves dual purposes in this patient:

• Definitive anatomic assessment to confirm or exclude obstructive coronary artery disease as the cause of cardiomyopathy. 1

• Immediate ability to guide revascularization decisions, with fractional flow reserve (FFR) available during the procedure to functionally assess lesion severity. 1

• The ACR Appropriateness Criteria explicitly state that coronary angiography is the gold standard when ischemic heart disease needs to be definitively excluded or confirmed. 1

Important Clinical Considerations

Revascularization decisions depend on identifying obstructive coronary disease, and only invasive coronary angiography provides the definitive anatomic detail necessary for treatment planning. 1