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

Coronary Angiography

Proceed directly to invasive coronary angiography—this is the most appropriate next investigation for this patient with severely reduced LVEF (30%), regional wall motion abnormality (anterior wall hypokinesia), and classic heart failure symptoms. 1

Rationale for 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 coronary artery disease rather than non-ischemic cardiomyopathy 1
• The combination of severely reduced LVEF, regional wall abnormality, and heart failure symptoms makes coronary artery disease the most likely cardiac cause 1, 2

Invasive catheter coronary angiography is the clinical gold standard to definitively diagnose coronary artery disease in patients with suspected ischemic cardiomyopathy 1, 2. The American College of Radiology explicitly recommends coronary angiography as the most appropriate next investigation for patients with this clinical profile 1.

Why Not Other Options?

CT Coronary Angiography (Option B)

• While CT coronary angiography has excellent sensitivity, it has relatively low specificity in high-risk patients like this one 1
• It is less appropriate when definitive diagnosis is needed for treatment decisions, particularly when revascularization may be required 1

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 1
• Time to revascularization matters in ischemic cardiomyopathy, and this patient already has echocardiographic evidence suggesting coronary disease 1

Chest X-ray (Option D)

• While chest radiography can identify cardiomegaly and pulmonary congestion, it does not provide information about the underlying etiology of the cardiomyopathy 2, 3
• The patient has already undergone echocardiography, which is more definitive for cardiac assessment 2

Clinical Decision-Making

Revascularization decisions depend on identifying obstructive coronary disease, and coronary angiography is necessary for definitive anatomic assessment 1. During the procedure, fractional flow reserve (FFR) can be performed to functionally assess lesion severity and guide revascularization decisions 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.