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%?

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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

Why Not Other Options?

Myocardial perfusion imaging (Option A):

  • Delays definitive diagnosis when regional wall motion abnormalities are already present on echocardiography 1
  • Time to revascularization matters in ischemic cardiomyopathy, and delaying with non-invasive testing can negatively impact patient outcomes 1

CT coronary angiography (Option B):

  • Has excellent sensitivity but relatively low specificity in high-risk patients like this one 1
  • Less appropriate when definitive diagnosis is needed for treatment decisions 1
  • The American College of Radiology explicitly states that coronary angiography is the gold standard when ischemic heart disease needs to be definitively excluded or confirmed 1

Chest X-ray (Option D):

  • Already completed as part of initial evaluation 3
  • Does not provide information about coronary anatomy or guide revascularization decisions 1

Clinical Decision-Making

  • Revascularization decisions depend on identifying obstructive coronary disease, and coronary angiography is necessary for definitive anatomic assessment 1
  • Fractional flow reserve (FFR) can be performed during angiography to functionally assess lesion severity and guide revascularization decisions 1
  • This approach allows for both diagnosis and potential therapeutic intervention in a single procedure 1

Answer: C. Coronary angiography

References

1
Guideline

Diagnostic Approach for Ischemic Cardiomyopathy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Cardiac-Related Diagnoses for Dyspnea

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Diagnostic Approach to Dyspnea on Exertion

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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