From the Guidelines
Heart failure investigations should include a comprehensive panel of tests, with a 12-lead electrocardiogram, echocardiography, and measurement of natriuretic peptides being essential components, as recommended by the 2016 ESC guidelines 1.
Initial Evaluation
The initial evaluation of a patient with suspected heart failure should include:
- A complete blood count
- Comprehensive metabolic panel, including sodium, potassium, urea, creatinine, and estimated glomerular filtration rate (eGFR) 1
- Thyroid function tests, including TSH
- Brain natriuretic peptide (BNP or NT-proBNP) measurement, with levels above 100 pg/mL or NT-proBNP above 300 pg/mL strongly suggesting heart failure
- A 12-lead electrocardiogram to determine heart rhythm, heart rate, QRS morphology, and QRS duration, and to detect other relevant abnormalities 1
Imaging Studies
- Echocardiography is essential to assess cardiac structure and function, particularly left ventricular ejection fraction, which classifies heart failure as reduced (HFrEF, <40%), mid-range (HFmrEF, 40-49%), or preserved (HFpEF, ≥50%) 1
- Chest X-ray can identify cardiomegaly, pulmonary congestion, or alternative pulmonary causes
- For selected patients, cardiac MRI provides detailed tissue characterization, while coronary angiography assesses coronary artery disease as a potential cause
Additional Tests
- Exercise stress testing evaluates functional capacity and exertional symptoms, and is recommended as part of the evaluation for heart transplantation and/or mechanical circulatory support 1
- Holter monitoring may detect arrhythmias contributing to heart failure
- Right heart catheterization with a pulmonary artery catheter is recommended in patients with severe heart failure being evaluated for heart transplantation or mechanical circulatory support 1
These investigations are crucial because they not only confirm the diagnosis but also identify specific etiologies like ischemic heart disease, valvular abnormalities, or cardiomyopathies, allowing for targeted treatment approaches rather than generic heart failure management.
From the Research
Heart Failure Investigations
Heart failure investigations involve various tests to diagnose and manage the condition. The following are some of the key investigations used:
- Echocardiography: remains the most common investigation due to its low cost and reproducible nature, allowing quantification of left ventricular function, which is an important prognostic marker in heart failure 2
- Cardiac magnetic resonance imaging: allows identification of potential reversible causes and further identification of underlying causes when other modalities fail to do so 2
- Computed tomography coronary angiography: currently recommended test in all patients presenting with typical or atypical anginal symptoms, diagnostically comparable to invasive coronary angiography 2
- Electrocardiogram (ECG) and chest X-ray: although not sufficient to reliably predict heart failure, an abnormal ECG had an estimated sensitivity of 81% and negative predictive value of 75%, while an abnormal chest X-ray had an estimated sensitivity of 57% and negative predictive value of 83% 3
- Biomarker level, imaging tools, score-based algorithms, and invasive evaluation: should be based on the strengths and weaknesses of each test to help diagnose heart failure with preserved ejection fraction (HFpEF) 4
Diagnostic Guidelines
The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure provides patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure, including: