Is this a picture of heart failure?

I Cannot Diagnose Heart Failure From a Picture Alone

Heart failure is a clinical syndrome requiring the integration of symptoms, physical examination findings, laboratory data (especially natriuretic peptides), and imaging studies—not a single image. 1, 2

Why a Picture Is Insufficient

• Heart failure diagnosis requires three mandatory components: (1) symptoms and/or signs of heart failure, (2) structural or functional cardiac abnormality, and (3) either elevated natriuretic peptides or objective evidence of congestion 1

• Clinical context is essential: The same imaging finding can represent heart failure in one patient but be incidental in another without symptoms or elevated biomarkers 3

What You Actually Need for Diagnosis

Essential Clinical Data

• Symptoms to assess: dyspnea, fatigue, orthopnea, paroxysmal nocturnal dyspnea, or exercise intolerance 1, 2

• Physical examination signs: jugular venous distension, third heart sound (S3), displaced cardiac apex, peripheral edema, pulmonary rales, or hepatomegaly 2, 4

• Natriuretic peptide levels: BNP >35 pg/mL (ambulatory) or >100 pg/mL (hospitalized), or equivalent NT-proBNP values 1, 3

Critical Diagnostic Tests

• Echocardiography is the diagnostic standard to confirm heart failure by assessing left ventricular ejection fraction, chamber dimensions, wall thickness, valve function, and diastolic parameters 3, 2

• ECG and chest X-ray provide supportive data: A completely normal ECG makes heart failure unlikely, especially systolic dysfunction; chest X-ray can show cardiomegaly or pulmonary congestion but has limited predictive value alone 3

• Laboratory evaluation: Complete blood count, electrolytes, creatinine, glucose, liver enzymes, and thyroid function to identify contributing factors 3, 4

Common Diagnostic Pitfalls

• A single abnormal finding does not equal heart failure: Cardiomegaly on imaging, an abnormal ECG, or even reduced ejection fraction can exist without the clinical syndrome of heart failure 3

• Normal imaging does not exclude heart failure with preserved ejection fraction (HFpEF): Up to 40-50% of heart failure patients have preserved left ventricular function, requiring elevated natriuretic peptides and evidence of diastolic dysfunction for diagnosis 2, 1

• Obesity complicates diagnosis: Physical examination is less reliable, imaging quality is reduced, and BNP levels may be falsely low in obese patients 5

The Diagnostic Algorithm

1. Start with clinical suspicion: Assess for symptoms (dyspnea, fatigue, edema) and risk factors (coronary disease, hypertension, diabetes, valvular disease) 4, 6

2. Obtain natriuretic peptides: Low-normal BNP/NT-proBNP in an untreated patient makes heart failure unlikely 3, 1

3. Perform echocardiography if peptides are elevated or clinical suspicion is high: Determine ejection fraction, assess for structural abnormalities (valve disease, chamber enlargement, wall thickness), and evaluate diastolic function 3, 1

4. Integrate all findings: Heart failure diagnosis requires concordance between symptoms, biomarkers, and cardiac structural/functional abnormalities 1, 2