What tests are recommended for assessing heart wellbeing?

Tests for Heart Wellbeing Assessment

For comprehensive heart health assessment, obtain a 12-lead ECG, lipid profile (including LDL-C), complete blood count, renal function tests, fasting glucose/HbA1c, and transthoracic echocardiography to evaluate cardiac structure and function. 1

Essential Initial Tests

Blood Tests (Required for All Patients)

• Lipid profile including LDL cholesterol - identifies atherogenic risk and guides cardiovascular disease prevention 1
• Complete blood count - detects anemia which can cause cardiac symptoms and worsen heart failure 1
• Creatinine with estimated glomerular filtration rate - assesses renal function which impacts cardiac medication dosing and prognosis 1
• Fasting glucose and/or HbA1c - screens for diabetes, a major cardiovascular risk factor 1
• Thyroid function (TSH) - should be assessed at least once, as thyroid dysfunction affects cardiac function 1

Electrocardiogram

• Resting 12-lead ECG is mandatory for all individuals with chest pain or suspected cardiac disease 1
• Identifies arrhythmias, conduction abnormalities, prior myocardial infarction, and ventricular hypertrophy 1
• Should be obtained during or immediately after symptoms suggestive of myocardial ischemia 1

Cardiac Imaging

Transthoracic echocardiography is the cornerstone imaging test and should be performed to: 1

• Measure left ventricular ejection fraction (LVEF), volumes, and diastolic function
• Identify regional wall motion abnormalities suggesting coronary disease
• Detect non-coronary cardiac disease (cardiomyopathy, valve disease, pericardial effusion)
• Assess right ventricular function and pulmonary artery pressure
• Refine risk stratification and guide treatment decisions

Risk-Stratified Advanced Testing

For Suspected Coronary Artery Disease

The choice of advanced testing depends on pre-test probability and exercise capacity:

Patients Who Can Exercise (Interpretable ECG)

• Exercise ECG testing is recommended for assessing exercise tolerance, symptoms, arrhythmias, and blood pressure response in selected patients 1
• However, exercise ECG alone is not recommended if coronary CT angiography (CCTA) or functional imaging tests are available when pre-test probability is low-to-moderate (>5-50%) 1

Patients Who Can Exercise (Uninterpretable ECG)

• Stress echocardiography or stress cardiac MRI is recommended for those with moderate-to-high pre-test probability (>15-85%) 1
• These tests diagnose myocardial ischemia and estimate risk of major adverse cardiac events 1

Patients Unable to Exercise

• Pharmacologic stress with radionuclide myocardial perfusion imaging or echocardiography is recommended regardless of ECG interpretability 1
• Provides assessment of ischemia and ventricular function when exercise testing is not feasible 1

Anatomical Coronary Assessment

Coronary CT angiography (CCTA) is recommended in individuals with low-to-moderate pre-test probability (>5-50%) to: 1

• Diagnose obstructive coronary artery disease
• Estimate risk of major adverse cardiac events
• Refine diagnosis when other non-invasive tests are non-diagnostic

CCTA should not be used in patients with severe renal failure (eGFR <30 mL/min/1.73 m²), decompensated heart failure, extensive coronary calcification, fast irregular heart rate, or severe obesity 1

Additional Specialized Tests

Natriuretic Peptides

• BNP or NT-proBNP measurement should be considered to exclude alternative causes of dyspnea (if below exclusion cut-point, heart failure is very unlikely) and obtain prognostic information 1
• Particularly useful when clinical diagnosis is uncertain 1

Chest Radiography

• Should be considered to detect/exclude lung disease and identify pulmonary congestion in acute presentations 1
• Limited value for chronic stable patients with high coronary disease probability 1

Cardiac Catheterization

• Coronary angiography is recommended in patients with angina who are considered suitable for coronary revascularization 1
• Left and right heart catheterization is indicated when evaluating for heart transplantation or mechanical circulatory support 1

Common Pitfalls to Avoid

• Do not use exercise ECG in patients with ≥0.1 mV ST-segment depression at rest, left bundle branch block, or those on digitalis 1
• Avoid routine reassessment (<1 year) of left ventricular function in patients with no clinical change 1
• Do not perform pharmacologic stress imaging in patients who can exercise adequately with interpretable ECG 1
• Never rely on total cholesterol alone - always measure HDL cholesterol and triglycerides for complete cardiovascular risk assessment 2, 3