In a 58-year-old patient with progressive dyspnea, paroxysmal nocturnal dyspnea, anterior wall hypokinesia and left ventricular ejection fraction of 30%, which is the next best investigation: myocardial perfusion scan, CT angiography, coronary angiography, or chest X‑ray?

Coronary Angiography is the Next Best Investigation

In this 58-year-old patient with heart failure symptoms (progressive dyspnea, paroxysmal nocturnal dyspnea), severely reduced ejection fraction (30%), and anterior wall hypokinesia on echocardiography, coronary angiography is the definitive next investigation to determine if ischemic heart disease is the underlying cause. 1

Clinical Reasoning

Why This Patient Needs Coronary Assessment

• Regional wall motion abnormality (anterior wall hypokinesia) strongly suggests ischemic cardiomyopathy rather than a global cardiomyopathy, as ischemic disease produces regional dysfunction patterns while non-ischemic causes typically produce diffuse dysfunction. 1

• Coronary artery disease is the most common cardiac cause of dyspnea and the major source of heart failure with reduced ejection fraction (HFrEF). 2 In patients with severely reduced LVEF and regional wall motion abnormalities, ischemic cardiomyopathy must be definitively confirmed or excluded. 1

• The American College of Radiology explicitly states that invasive catheter coronary angiography remains the clinical gold standard to diagnose coronary artery disease in patients without a prior diagnosis when CAD should be excluded as a potential etiology of impaired left ventricular function. 3, 1

Why Coronary Angiography Over Other Options

Coronary angiography is rated as "usually appropriate" (rating 8/9) by ACR guidelines for patients with heart failure where ischemia is not excluded, particularly when there is high pretest probability of ischemic disease. 3

Why Not Myocardial Perfusion Scan?

• While myocardial perfusion imaging (SPECT/PET) is also rated as appropriate (rating 9), it provides functional information about ischemia but does not definitively identify coronary anatomy or guide revascularization decisions. 3

• In a patient with already-documented regional wall motion abnormality and severely reduced ejection fraction, the priority is anatomic coronary assessment to determine revascularization candidacy, not additional functional testing. 1

Why Not CT Angiography?

• CT coronary angiography has limited utility in high-risk patients due to low specificity from heavy calcification, small vessels, and motion artifacts that may be falsely interpreted as stenosis. 3, 2

• The ACR guidelines recommend proceeding directly to invasive angiography when revascularization is being considered rather than using CT angiography as an intermediate step. 2

• CT angiography is rated as appropriate (rating 8) but has excellent sensitivity with relatively low specificity in high-risk patients, making it less appropriate when definitive diagnosis is needed for treatment decisions. 1

Why Not Chest X-Ray?

• Chest X-ray is appropriate for initial evaluation of heart failure (rating 9) to identify cardiomegaly, pulmonary congestion, and pleural effusions. 3, 2

• However, this patient already has confirmed heart failure with documented severe LV dysfunction on echocardiography, so chest X-ray would not change management or provide the critical information needed—namely, whether coronary disease is present and amenable to revascularization. 2

Clinical Impact on Management

Revascularization Considerations

• Fractional flow reserve (FFR) can be performed during coronary angiography to functionally assess lesion severity and guide revascularization decisions, providing both anatomic and functional assessment in a single procedure. 3, 1

• Randomized controlled trials demonstrate long-term benefit from coronary artery bypass grafting (CABG) compared to medical treatment alone in patients with HFrEF and severe coronary heart disease, with a hazard ratio for death of 0.84 (95% CI: 0.73-0.97) after nearly 10 years of follow-up. 4

• Time to revascularization matters in ischemic cardiomyopathy—delaying definitive coronary assessment with non-invasive testing when regional wall motion abnormalities are present can negatively impact patient outcomes. 1

Prognostic Implications

• Distinguishing ischemic from non-ischemic etiology is critical because patients with ischemic cardiomyopathy may benefit from revascularization, while those with non-ischemic causes require different management strategies. 3, 5

• Non-ischemic etiology is a clinical predictor of myocardial recovery (improvement in LVEF ≥40% can be achieved in 10-40% of HFrEF patients with guideline-directed medical therapy), so establishing the etiology guides both treatment and prognosis discussions. 5

Common Pitfalls to Avoid

• Do not delay definitive coronary assessment with sequential non-invasive testing when clinical presentation strongly suggests ischemic cardiomyopathy (regional wall motion abnormality + severely reduced EF). 1

• Do not assume that normal chest radiography excludes cardiac disease—it cannot exclude early heart failure or diastolic dysfunction and provides no information about coronary anatomy. 2

• Do not rely on CT coronary angiography in patients likely to have significant coronary calcification (age 58 with heart failure symptoms), as this reduces specificity and may necessitate invasive angiography anyway. 3, 2