Should a cardiac angiogram be performed to evaluate the reason for heart failure with reduced ejection fraction (HFrEF) in a newly diagnosed patient with severely reduced left ventricular systolic function, mild concentric left ventricular hypertrophy, and multiple other cardiac abnormalities?

Should This Patient Undergo Coronary Angiography?

Yes, coronary angiography is reasonable and should be strongly considered in this patient with newly diagnosed HFrEF (EF 30-35%) to determine if ischemic heart disease is the underlying cause, as this distinction fundamentally alters treatment strategy and prognosis.

Rationale for Coronary Evaluation in New-Onset HFrEF

The distinction between ischemic and nonischemic cardiomyopathy is critical because patients with ischemic HFrEF can experience dramatic improvement with revascularization, making prompt differentiation essential 1. Coronary artery disease remains a major source of HFrEF nationally, and identifying reversible ischemic injury guides both immediate and long-term management 1.

Guideline-Based Indications

ACC/AHA guidelines provide clear direction for this clinical scenario:

• Class IIa recommendation: Coronary arteriography is reasonable for patients presenting with HF who have known or suspected coronary artery disease but who do not have angina, unless the patient is not eligible for revascularization 1

• Class IIa recommendation: Coronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac origin, who have not had evaluation of their coronary anatomy, and who have no contraindications to coronary revascularization 1

• The 2018 ACR Appropriateness Criteria specifically state that coronary CTA or coronary arteriography is "usually appropriate" if there is high pretest probability or symptoms for ischemic disease when HFrEF is confirmed 1

Important Caveats About Risk Factor-Only Patients

One critical limitation must be acknowledged: In patients presenting with new-onset HFrEF with only risk factors (without angina), coronary angiography has been shown NOT to be beneficial in differentiating between ischemic and nonischemic etiologies 1. A study of 107 patients with new-onset HFrEF found that in the subgroup who were symptomatic but had only risk factors predisposing to CAD (no angina), invasive coronary angiography did not detect any cases of obstructive disease 1.

Patient-Specific Considerations

For this specific patient, several factors support proceeding with angiography:

• Newly diagnosed severe HFrEF (EF 30-35%) with severe global hypokinesis and apical dyskinesis 2
• Mild concentric LVH present, which could suggest chronic hypertension or ischemic remodeling
• No mention of angina or chest pain in the provided data, which places this patient in a gray zone
• Age and body habitus (BMI 33.9, male pattern typical for CAD risk)

Alternative Noninvasive Approaches

If you want to avoid immediate invasive angiography, the following noninvasive strategies are supported by guidelines:

Cardiac MRI with Late Gadolinium Enhancement (Preferred Noninvasive Option)

• Diagnostic accuracy comparable to angiography: LGE MRI has sensitivity 67-100%, specificity 96-100%, positive predictive value 100%, negative predictive value 90%, and diagnostic accuracy 97% for detecting ischemic LV myocardial damage—comparable to coronary angiography (sensitivity 93%, specificity 96%, accuracy 95%) 1

• Can serve as gatekeeper: MRI with LGE is suggested as a safe, clinically effective, and potentially economical gatekeeper to coronary angiography in patients presenting with HFrEF 1

• Pattern recognition: The presence of an ischemic pattern on both LGE and cine imaging has specificity of 87%, while the absence of both has specificity of 94% for a nonischemic cause 1

• Important limitation: Cannot completely exclude an ischemic etiology when LGE is absent 1

Coronary CT Angiography

• High negative predictive value: A CT algorithm (including coronary CTA when initial coronary calcium score >0) has sensitivity 100%, specificity 95%, positive predictive value 67%, and negative predictive value 100% for detecting ischemic etiology in new-onset HFrEF 1

• Calcium score = 0 excludes CAD: CT coronary calcium score of 0 alone may be used to exclude CAD and potentially obviate the need for coronary angiography 1

• Patients with score = 0 or no significant CAD on CTA are not expected to have subsequent coronary events 1

Stress Testing Options (Less Preferred)

• Stress echocardiography: Can identify resting and post-stress systolic wall motion abnormalities that correlate with clinical outcomes 1

• SPECT/CT MPI: Has excellent sensitivity and negative predictive value for detecting CAD in HFrEF patients, though distinguishing ischemic from nonischemic etiology can be challenging 1

• PET perfusion imaging: Improved accuracy for detecting severe, multivessel CAD compared to SPECT alone 1

Recommended Clinical Algorithm

Step 1: Assess for angina or anginal equivalents

• If present → Proceed directly to coronary angiography (Class I indication) 1
• If absent → Proceed to Step 2

Step 2: Evaluate CAD risk factors and pretest probability

• High pretest probability (multiple risk factors, ECG changes suggesting prior MI) → Consider coronary angiography (Class IIa) 1
• Low-to-intermediate pretest probability → Proceed to Step 3

Step 3: Consider noninvasive testing first

• Preferred: Cardiac MRI with LGE to characterize myocardium 1
• Alternative: Coronary CTA with calcium scoring 1
• If ischemic pattern identified → Proceed to coronary angiography
• If clearly nonischemic → Avoid angiography unless clinical status changes 1

Critical Pitfalls to Avoid

• Do not delay echocardiography: Already completed appropriately in this case 2

• Do not perform angiography in patients with only risk factors and no angina if you're trying to differentiate etiology: This has been shown not to be beneficial 1

• Do not assume angiography is always necessary: In patients where CAD has been excluded as the cause of HFrEF, coronary angiography is generally not indicated unless clinical status changes 1

• Consider revascularization eligibility: Angiography should not be performed if the patient is not a candidate for any form of revascularization 1

Impact on Mortality and Quality of Life

Why this matters for outcomes:

• Ischemic cardiomyopathy patients can potentially have dramatic improvement with specific therapy, including revascularization 1
• The STICH trial extension showed that CABG plus medical therapy was superior to medical therapy alone in HFrEF patients with CAD amenable to CABG for all-cause mortality and cardiovascular hospitalization 1
• Five-year survival after hospitalization for HFrEF is only 25%, making accurate diagnosis and appropriate intervention critical 3
• Identifying ischemic etiology allows for targeted therapies beyond standard HFrEF management 1

Bottom Line for This Patient

Given this patient's newly diagnosed severe HFrEF without documented angina, the most reasonable approach is:

1. If resources and expertise available: Obtain cardiac MRI with LGE first to characterize the myocardium and guide need for angiography 1

2. If MRI unavailable or contraindicated: Proceed with coronary angiography given the Class IIa recommendation for patients with known/suspected CAD without angina 1

3. If patient has any chest discomfort or anginal equivalents not documented: Proceed directly to coronary angiography (Class I indication) 1

The key is that this decision should not be delayed, as prompt differentiation of ischemic from nonischemic HFrEF is essential for optimal management and potential revascularization 1, 2.