What is the most appropriate next step in management for a patient with progressive dyspnea, anterior wall hypokinesia, ejection fraction 30%, and bradycardia on electrocardiogram?

Management of Progressive Dyspnea with Anterior Wall Hypokinesia, EF 30%, and Bradycardia

Coronary angiography is the most appropriate next step in management for this patient. 1

Rationale for Invasive Coronary Angiography

This patient presents with a clinical picture highly suggestive of ischemic cardiomyopathy requiring urgent diagnostic clarification:

• Regional wall motion abnormality (anterior wall hypokinesia) is highly specific for coronary artery disease rather than non-ischemic dilated cardiomyopathy, which typically presents with global hypokinesis. 1

• New-onset heart failure with reduced ejection fraction (30%) and regional wall motion abnormality mandates coronary angiography as the gold standard diagnostic test to determine if revascularization is needed. 1

• Progressive dyspnea with severely reduced ejection fraction represents a high-risk presentation that may indicate acute coronary syndrome without ST elevation, even in the absence of classic STEMI findings on ECG. 1

• The absence of obvious STEMI on ECG does not exclude acute coronary occlusion or critical stenosis requiring urgent intervention. 1

Why Not Non-Invasive Testing First?

Stress testing (including myocardial perfusion scan) is contraindicated in decompensated heart failure and provides no actionable information when coronary angiography is already indicated based on regional wall motion abnormalities. 1

• Delaying angiography to wait for stress testing in patients with new heart failure and regional wall motion abnormalities increases risk without benefit. 1

• CT coronary angiography, while rated 8/9 for dyspnea evaluation, is not the optimal choice when invasive angiography is already indicated for both diagnosis and potential immediate intervention. 2

• The American College of Cardiology recommends proceeding directly to coronary angiography when regional wall motion abnormality is present in new heart failure with reduced ejection fraction. 1

Clinical Decision Algorithm

For patients with new heart failure and reduced EF with regional wall motion abnormality:

• Proceed directly to coronary angiography if any of the following are present: 1

  • Regional wall motion abnormality (present in this case)
  • Hemodynamic instability or ongoing ischemic symptoms
  • Electrical instability (bradycardia present in this case)

• Emergency angiography is recommended if hemodynamically unstable or ongoing ischemic symptoms are present. 1

• Urgent angiography is recommended if electrically unstable with arrhythmias. 1

Expected Management Following Angiography

If obstructive coronary disease is identified:

• Percutaneous coronary intervention for culprit lesions improves outcomes in ischemic cardiomyopathy. 1

• Complete revascularization should be considered for multivessel disease with viable myocardium. 1

• Guideline-directed medical therapy including beta-blockers, ACE inhibitors, and aldosterone antagonists should be initiated. 1

Critical Pitfalls to Avoid

• Do not assume non-ischemic etiology based on absence of chest pain, as elderly patients and those with heart failure frequently present with atypical symptoms (dyspnea alone). 1

• Do not delay angiography waiting for troponin results or stress testing in patients with new heart failure and regional wall motion abnormalities. 1

• Do not perform stress testing in decompensated heart failure, as this increases risk without providing actionable information. 1

• The bradycardia on ECG may represent high-grade ischemia or conduction system disease requiring urgent evaluation and potential temporary pacing during angiography. 3