Do guideline recommendations for Heart Failure with Reduced Ejection Fraction (HFrEF) include cardiac catheterization or Coronary Computed Tomography Angiography (CTA)?

Guideline Recommendations for HFrEF: Role of Cardiac Catheterization and Coronary CTA

Current guidelines recommend cardiac catheterization or coronary CTA in specific clinical scenarios for HFrEF patients, particularly when coronary artery disease is suspected as the underlying etiology, but these are not routine first-line recommendations for all HFrEF patients. 1

Diagnostic Evaluation in HFrEF

Cardiac Catheterization Recommendations:

• Invasive coronary angiography (ICA) is recommended in HF patients with LVEF ≤35% in whom obstructive CAD is suspected, with a view toward improving prognosis through CABG 1
• Hemodynamic assessment with right heart catheterization is recommended for:
  • Patients with severe HF being considered for heart transplantation or mechanical circulatory support 1
  • Selected patients with persistent HF symptoms despite standard therapies
  • Patients requiring vasopressor support
  • Patients with uncertain volume or perfusion status 1

Coronary CTA Recommendations:

• CCTA is recommended in HF patients with LVEF >35% and suspected coronary artery disease with low-to-intermediate pre-test likelihood (>5%-50%) of obstructive CAD 1
• CCTA is also recommended for HF patients with equivocal non-invasive stress test results 1
• CCTA should be avoided in patients with contraindications to contrast administration 1

Clinical Decision Algorithm for Imaging in HFrEF

1. Initial evaluation: All HFrEF patients should receive basic workup including history, physical examination, ECG, chest X-ray, and transthoracic echocardiography 1

2. For patients with LVEF ≤35%:

   • If obstructive CAD is suspected → Proceed directly to invasive coronary angiography (Class I, Level B) 1
   • If severe HF requiring advanced therapies → Consider right heart catheterization (Class I) 1

3. For patients with LVEF >35%:

   • If low-to-moderate pre-test probability of CAD → CCTA or functional imaging (Class I, Level C) 1
   • If very high pre-test probability of CAD (>85%) → Invasive coronary angiography (Class I, Level C) 1

Important Considerations and Pitfalls

• Endomyocardial biopsy is not recommended for routine assessment of unexplained cardiomyopathy (Class III) 1
• Endomyocardial biopsy should only be considered in patients with rapidly progressive HF despite treatment, worsening ventricular dysfunction, or for specific conditions where targeted therapy is available (e.g., sarcoidosis, giant cell myocarditis) 1
• Cardiac magnetic resonance (CMR) with late gadolinium enhancement should be considered to distinguish between ischemic and non-ischemic myocardial damage and assess scarring (Class IIa) 1
• Non-invasive stress testing may be difficult in HF patients due to exercise intolerance 1

Guideline-Directed Medical Therapy (GDMT)

While imaging has an important role in diagnosis and risk stratification, the cornerstone of HFrEF management remains GDMT, which includes:

• Four medication classes: ACE inhibitors/ARBs/ARNIs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors 1, 2
• Loop diuretics for symptom relief in volume-overloaded patients 1, 2
• Device therapy (ICD, CRT) in appropriate candidates 1

The 2022 AHA/ACC/HFSA guidelines emphasize that GDMT should be optimized before considering advanced interventions, and that imaging studies should be directed by clinical suspicion of specific etiologies or complications 1.

In summary, cardiac catheterization and coronary CTA are important diagnostic tools in HFrEF management, but their use should be targeted based on clinical suspicion of coronary artery disease, need for advanced therapies, or unclear hemodynamic status rather than as routine tests for all HFrEF patients.