A 52-year-old man with a history of hypertension presents with dyspnea on exertion and orthopnea. Clinical examination reveals elevated JVP, peripheral edema, and a displaced apex beat. Chest X-ray shows pulmonary edema. Which investigation would be most appropriate to quantify the degree of left ventricular dysfunction and guide therapy?

Explanation

## Investigation of Choice for Quantifying LV Dysfunction **Key Point:** Transthoracic echocardiography with Doppler is the first-line, non-invasive investigation for assessing left ventricular ejection fraction (LVEF), wall motion abnormalities, and diastolic function in suspected heart failure. ### Why Echocardiography is Optimal 1. **Non-invasive and readily available** — can be performed at the bedside or in outpatient clinics 2. **Quantifies LVEF** — essential for diagnosis and classification of heart failure (HFrEF vs HFpEF) 3. **Assesses wall motion** — identifies regional dysfunction suggestive of coronary artery disease 4. **Evaluates diastolic function** — Doppler mitral inflow and tissue Doppler patterns 5. **Guides therapeutic decisions** — determines eligibility for ACE inhibitors, beta-blockers, aldosterone antagonists, and device therapy (CRT, ICD) 6. **Cost-effective and repeatable** — allows serial monitoring of response to therapy ### Comparison of Investigations | Investigation | Indication | Limitation | |---|---|---| | **Transthoracic echo** | First-line assessment of LV function, wall motion, valves | Limited acoustic window in obese/emphysematous patients | | Cardiac catheterization | Coronary angiography when CAD suspected; invasive hemodynamics | Invasive; not first-line for LV function assessment | | Cardiac MRI | High-risk myocarditis, infiltrative disease, scar quantification | Expensive, not first-line; contraindicated with certain implants | | MUGA scan | LVEF quantification when echo non-diagnostic; serial monitoring | Radiation exposure; less structural detail than echo | **Clinical Pearl:** In this patient with clinical signs of heart failure and pulmonary edema, echocardiography will immediately reveal the mechanism (systolic vs diastolic dysfunction) and guide initiation of guideline-directed medical therapy without delay. **High-Yield:** LVEF < 40% defines HFrEF and mandates ACE-I/ARB + beta-blocker ± aldosterone antagonist; LVEF ≥ 50% with diastolic dysfunction suggests HFpEF, managed differently.