Does new onset heart failure with reduced ejection fraction (HFrEF) require stress test or cardiac catheterization?

From the Guidelines

For new onset heart failure with reduced ejection fraction (HFrEF), a non-invasive stress test is typically the initial preferred option, rather than cardiac catheterization, to help identify coronary artery disease as a potential cause of HFrEF. This approach is supported by the American College of Radiology [ 1 ], which emphasizes the importance of distinguishing between ischemic and nonischemic etiologies in HFrEF. The choice between stress testing and cardiac catheterization should be made based on the patient's clinical presentation, risk factors, and overall health status.

Key Considerations

• A non-invasive stress test, such as a stress echocardiogram or nuclear stress test, is usually the initial preferred option [ 1 ].
• Cardiac catheterization may be necessary in certain situations, such as:
  1. If the stress test is positive or inconclusive
  2. If there's a high clinical suspicion of severe coronary artery disease
  3. In cases of acute heart failure or cardiogenic shock
  4. When considering advanced therapies like transplant or mechanical circulatory support
• The goal is to identify the underlying cause of HFrEF and guide appropriate treatment [ 1 ].

Initial Management

Regardless of the chosen test, initial management typically includes starting guideline-directed medical therapy for HFrEF, which often includes:

• ACE inhibitor or ARB (e.g., lisinopril 2.5-5mg daily, titrated up as tolerated)
• Beta-blocker (e.g., metoprolol succinate 12.5-25mg daily, titrated up as tolerated)
• Mineralocorticoid receptor antagonist (e.g., spironolactone 12.5-25mg daily)
• Diuretics for symptom relief (e.g., furosemide 20-40mg daily, adjusted based on symptoms) These medications should be initiated and uptitrated as tolerated while awaiting further cardiac evaluation results [ 1 ].

From the Research

Diagnosis and Treatment of New-Onset Heart Failure with Reduced Ejection Fraction (HFrEF)

• The diagnosis and treatment of new-onset HFrEF involve assessing the underlying cause of the condition, with cardiac ischemia being a common cause 2.
• Guidelines recommend the initiation of class I guideline-directed medical therapies, including renin-angiotensin system inhibitors (RASI) or angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i) following the diagnosis of HFrEF 3, 4.
• The use of stress tests or cardiac catheterization may be necessary to assess coronary artery disease (CAD) in patients with new-onset HFrEF of unclear etiology 2.
• Non-invasive testing with radionuclide myocardial perfusion imaging, coronary CT angiography (CCTA), and cardiac magnetic resonance (CMR) imaging can be used as an alternative to invasive coronary angiography (ICA) for CAD assessment in this population 2.

Role of Stress Test or Cardiac Catheterization

• Stress testing or cardiac catheterization may be required to evaluate the presence and severity of CAD in patients with new-onset HFrEF 2, 5.
• The choice of diagnostic test depends on the individual patient's characteristics and the suspected underlying cause of HFrEF 2.
• Cardiac catheterization can provide detailed information about coronary artery anatomy and guide coronary revascularization in patients with ischemic cardiomyopathy 2.

Treatment Response and Outcomes

• Patients with new-onset HFrEF may have different responses to treatment compared to those with heart failure with preserved ejection fraction (HFpEF) 6.
• Ambulatory patients with new-onset HFrEF may have more severe functional symptoms and be less likely to respond to treatment compared to those with HFpEF 6.
• Goal-directed management and therapy should be initiated within 6 months of diagnosis to reduce morbidity and mortality in patients with HFrEF 5.