What are the diagnostic tests and treatment options for left ventricular failure?

Diagnosis of Left Ventricular Failure

The diagnosis of left ventricular failure requires two-dimensional echocardiography with Doppler to definitively assess left ventricular ejection fraction (LVEF), left ventricular size, wall thickness, and valve function—this is the single most critical diagnostic test that must be performed in all patients. 1

Initial Clinical Assessment

The diagnostic workup begins with specific clinical findings that increase diagnostic probability:

• Look for a displaced cardiac apex on palpation, which is highly specific for left ventricular dysfunction 2
• Auscultate for a third heart sound (S3 gallop), which strongly suggests volume overload and elevated filling pressures 3, 2
• Assess for jugular venous distension, hepatojugular reflux, peripheral edema, and pulmonary rales to evaluate volume status 3, 2
• Measure orthostatic blood pressure changes to guide volume assessment 1, 3
• Document weight, height, and calculate BMI as baseline for monitoring 1, 3
• Quantify functional capacity by assessing ability to perform activities of daily living and severity of dyspnea 1, 3

Critical History Elements

• Obtain detailed substance use history: alcohol consumption, illicit drugs (especially cocaine), chemotherapy exposure, and alternative therapies that may be cardiotoxic 1, 3
• Screen for coronary artery disease risk factors and anginal symptoms, as CAD is the most common cause of heart failure 1, 2
• Ask about diabetes, hypertension, and family history of cardiomyopathy 1

Essential Diagnostic Tests (Class I Recommendations)

Imaging Studies

• 12-lead ECG is mandatory to determine heart rhythm, heart rate, QRS morphology and duration, detect arrhythmias, conduction abnormalities, left ventricular hypertrophy, or evidence of prior myocardial infarction 1, 3
• Chest X-ray (PA and lateral views) to detect cardiomegaly, pulmonary venous congestion, interstitial edema, pleural effusions, Kerley B lines, and exclude alternative pulmonary diseases 1, 3
• Two-dimensional echocardiography with Doppler is the definitive diagnostic test and must be performed to assess LVEF, left ventricular size, wall thickness, regional wall motion abnormalities, and valve function 1, 3

Laboratory Testing

The following laboratory tests are recommended for initial assessment 1:

• Complete blood count (hemoglobin and WBC) 1
• Comprehensive metabolic panel: sodium, potassium, urea, creatinine with estimated GFR 1
• Liver function tests: bilirubin, AST, ALT, GGTP 1
• Glucose and HbA1c 1
• Thyroid-stimulating hormone (TSH) 1
• Ferritin, transferrin saturation (TSAT), and total iron-binding capacity (TIBC) 1
• Lipid profile 1

Natriuretic Peptides

• BNP or NT-proBNP measurement (Class IIa recommendation) should be considered when the clinical diagnosis remains uncertain after initial evaluation 1
• BNP is particularly useful in the emergency setting to differentiate dyspnea due to heart failure from other causes 1
• Normal BNP levels make systolic heart failure unlikely 2

Important caveat: While natriuretic peptides can identify heart failure, they cannot reliably distinguish systolic from diastolic dysfunction—echocardiography remains essential 1

Coronary Artery Disease Evaluation

Given that CAD is the most common cause of heart failure, coronary evaluation is critical 2:

• Invasive coronary angiography is mandatory (Class I) in patients with angina or significant ischemia who are eligible for revascularization 1
• Coronary angiography is reasonable (Class IIa) in patients with chest pain of uncertain cardiac origin or known/suspected CAD without angina, unless ineligible for revascularization 1
• Noninvasive imaging for ischemia and viability (Class IIa) is reasonable in patients with known CAD but no angina 1
• Cardiac CT may be considered (Class IIb) in patients with low to intermediate pre-test probability of CAD 1

Additional Diagnostic Tests in Selected Patients

When specific etiologies are suspected (Class IIa recommendation) 1:

• Screening for hemochromatosis, sleep-disturbed breathing, or HIV in selected patients 1
• Rheumatologic panel, amyloidosis testing, or pheochromocytoma workup when clinically suspected 1
• Endomyocardial biopsy can be useful when a specific diagnosis is suspected that would influence therapy, but should not be performed routinely 1

Exercise Testing

• Cardiopulmonary exercise testing is recommended (Class I) as part of evaluation for heart transplantation or mechanical circulatory support 1
• Exercise testing should be considered (Class IIa) to identify the cause of unexplained dyspnea or to optimize exercise training prescription 1

Right Heart Catheterization

• Recommended (Class I) in severe heart failure being evaluated for transplantation or mechanical circulatory support 1
• Should be considered (Class IIa) to assess pulmonary hypertension reversibility before valve/structural heart disease correction 1

Common Diagnostic Pitfalls to Avoid

• Never delay echocardiography—it is the definitive test to confirm heart failure and guide therapy 3
• Do not assume the diagnosis without objective evidence of left ventricular dysfunction 3
• Always consider reversible causes: peripartum cardiomyopathy, viral myocarditis, thyroid disease, alcohol-induced cardiomyopathy, undiagnosed valvular disease 3
• Do not rely on chest X-ray or ECG alone—both are insensitive and nonspecific and should not form the primary basis for determining the cardiac abnormality 1
• Framingham criteria, when not met, make systolic heart failure unlikely 2

Reassessment Timing

Reassessment of myocardial structure and function using non-invasive imaging is recommended 1:

• When patients present with worsening symptoms or experience any important cardiovascular event 1
• Before device implantation decisions (ICD, CRT) in patients who have received maximal evidence-based pharmacotherapy 1
• Serial assessments in patients exposed to cardiotoxic therapies (e.g., chemotherapy) 1