A 62-year-old woman with a history of diabetes and hypertension presents with dyspnea, fatigue, and ankle swelling for 4 weeks. On examination, she has a blood pressure of 145/92 mmHg, JVP elevation, bibasal crackles, and a laterally displaced apex beat. Echocardiography shows an ejection fraction of 35% with global hypokinesis and no wall motion abnormality. There is no evidence of primary valvular disease. Which investigation is most appropriate to exclude coronary artery disease as the etiology?

Question

Accepted Answer

D. Coronary angiography. ## Investigating CAD in HFrEF Without Regional Wall Motion Abnormality

**Key Point:** In a patient with HFrEF (EF ≤40%) and risk factors for coronary artery disease (diabetes, hypertension), coronary angiography is the gold-standard investigation to definitively exclude or confirm CAD as the etiology, regardless of whether wall motion abnormalities are present on TTE.

## Why Angiography Is Indicated Here

**High-Yield:** The absence of a **regional** wall motion abnormality does NOT exclude CAD. Global hypokinesis can occur in:
- **Non-ischemic dilated cardiomyopathy** (idiopathic, viral, infiltrative, toxic)
- **Ischemic cardiomyopathy with diffuse subendocardial ischemia** (from multivessel CAD or prior diffuse MI)
- **Balanced ischemia** (all territories equally affected)

In a patient with multiple CAD risk factors (diabetes, hypertension, age >60), the pretest probability of CAD is high. Angiography is the only test that can definitively establish the presence or absence of coronary stenosis and guide revascularization decisions.

**Clinical Pearl:** Guidelines recommend coronary angiography in all HFrEF patients with:
- Risk factors for CAD (diabetes, hypertension, smoking, dyslipidemia, age)
- Angina or anginal equivalent symptoms
- Abnormal stress test results
- Uncertainty about etiology despite non-invasive testing

## Comparison of Non-Invasive Stress Tests

| Test | Sensitivity | Specificity | Limitations in HFrEF |
|---|---|---|---|
| **Exercise treadmill** | 60–70% | 70–80% | Poor exercise tolerance; baseline ECG abnormalities; cannot reach target HR |
| **Dobutamine stress echo** | 80–85% | 84–86% | Arrhythmias; hypotension; inotrope-induced demand ischemia may not reflect true CAD |
| **Myocardial perfusion (SPECT)** | 85–90% | 70–75% | Attenuation artifact; false positives; cannot assess viability well in severe LV dysfunction |
| **Coronary angiography** | 95–99% | 99–100% | Invasive; contrast nephropathy risk; gold standard |

**Mnemonic: ANGIO-GOLD** — **A**natomic definition, **N**o false negatives, **G**old standard, **I**schemic vs. non-ischemic, **O**utcomes guide revascularization.

Answer

A. Dobutamine stress echocardiography

Answer

B. Myocardial perfusion imaging (SPECT)

Answer

C. Exercise treadmill test with ECG

Explanation

Investigating CAD in HFrEF Without Regional Wall Motion Abnormality

Why Angiography Is Indicated Here

Comparison of Non-Invasive Stress Tests

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Test	Sensitivity	Specificity	Limitations in HFrEF
Exercise treadmill	60–70%	70–80%	Poor exercise tolerance; baseline ECG abnormalities; cannot reach target HR
Dobutamine stress echo	80–85%	84–86%	Arrhythmias; hypotension; inotrope-induced demand ischemia may not reflect true CAD
Myocardial perfusion (SPECT)	85–90%	70–75%	Attenuation artifact; false positives; cannot assess viability well in severe LV dysfunction
Coronary angiography	95–99%	99–100%	Invasive; contrast nephropathy risk; gold standard