Investigations

1st investigations to order

transthoracic echocardiogram

Test
Result
Test

Allows for the accurate determination of biventricular systolic and diastolic function. Echocardiogram can also identify valvular, myocardial, or pericardial disease or may reveal evidence of underlying coronary artery disease (CAD) (regional wall motion/thickness abnormalities). A hypertrophied heart may be due to hypertension, hypertrophic obstructive cardiomyopathy, or infiltrative disease such as amyloidosis. It should be performed in every patient presenting with HF symptoms.

Result

HF with LVEF ≤40%: HF with reduced ejection fraction; LVEF 41% to 49%: HF with mildly reduced EF

ECG

Test
Result
Test

ECG may show evidence of underlying comorbidities. QRS duration above 120 ms should always raise the question of ventricular dyssynchrony.

Result

evidence of underlying coronary artery disease, left ventricular hypertrophy, or atrial enlargement; may be abnormal QRS duration; may identify comorbid conduction abnormalities

CXR

Test
Result
Test

May reveal pulmonary vascular congestion (vascular redistribution, Kerley B lines), cardiomegaly (increased cardiothoracic ratio), or pleural effusion (usually right-sided but often bilateral).

Result

abnormal

B-type natriuretic peptide (BNP)/N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels

Test
Result
Test

Elevated plasma BNP levels have been associated with reduced left ventricular ejection fraction, left ventricular hypertrophy, elevated left ventricular filling pressures, and acute myocardial infarction and ischaemia, although they can occur in other settings, such as pulmonary embolism and chronic obstructive pulmonary disease.[105][106][107]​ They are sensitive to other biological factors, such as age, sex, weight, and renal function. Elevated levels lend support to a diagnosis of abnormal ventricular function or haemodynamics causing symptomatic HF.[108][109][110]​ A low plasma BNP level (<100 nanograms/L or <100 picograms/mL) can rapidly rule out decompensated HF and point to a pulmonary cause. A high plasma BNP level (>400 nanograms/L or >400 picograms/mL) strongly supports the diagnosis of abnormal ventricular function (i.e., HF). Intermediate values (100-400 nanograms/L or 100-400 picograms/mL) fall into the so-called 'grey zone' and should spur a search for a potential non-cardiac cause of dyspnoea: for example, COPD. In patients presenting with dyspnoea, measurement of natriuretic peptide biomarkers is useful to support a diagnosis or exclude HF. However, elevated plasma levels of natriuretic peptides can occur with a wide variety of cardiac and non-cardiac causes; therefore, clinical judgement is necessary.​

In patients with relevant symptoms and/or signs, a BNP level of ≥35 nanograms/L (≥35 picograms/mL) in ambulatory patients and ≥100 nanograms/L (≥100 picograms/mL) in hospitalised patients, or NT-pro-BNP level of ≥125 nanograms/L (≥125 picograms/mL) in ambulatory patients and ≥300 nanograms/L (≥300 picograms/mL) in hospitalised patients, is suggestive of HF.[1]

Trials with this diagnostic marker suggest that its use may reduce both the time to hospital discharge and the cost of treatment.[111][112][113]​ BNP levels tend to be less elevated in HF with preserved ejection fraction than in HF with low ejection fraction and are lower in obese patients.[114] Levels of BNP may be elevated in women and in people over 60 years of age who do not have HF, and thus BNP levels should be interpreted cautiously in such individuals.[74][115][116]

Result

elevated

FBC

Test
Result
Test

Anaemia and high lymphocyte percentage are strong risk factors and prognostic markers of poor survival.

Result

laboratory testing may reveal important HF aetiologies, the presence of disorders or conditions that can lead to or exacerbate HF; laboratory testing could also reveal important modulators of therapy

urinalysis

Test
Result
Test

To measure renal function and assess for underlying comorbidities.

Result

may show proteinuria/albuminuria, glucosuria, 5-hydroxyindoleacetic acid (in patients with carcinoid heart disease)

serum electrolytes (including calcium and magnesium)

Test
Result
Test

Baseline electrolytes should be obtained in all patients.

Result

decreased sodium (usually <135 millimols/L), altered potassium

serum creatinine, urea

Test
Result
Test

Reflects tissue perfusion, fluid status, rules out renal disease.

Result

normal to elevated

blood glucose

Test
Result
Test

Screening for diabetes mellitus as a comorbid condition. Diabetes mellitus has been associated with a 3- to 5-fold increase in the risk of developing HF.[14][17][18][20][27][28]

Result

elevated in diabetes

LFT

Test
Result
Test

Reflects abdominal congestion.

Result

normal to elevated

thyroid function tests (especially thyroid-stimulating hormone [TSH])

Test
Result
Test

Screening for hypo- or hyperthyroidism. Both can be a primary or contributory cause of HF.

Result

primary hypothyroidism: elevated TSH, decreased free thyroxine (FT4); hyperthyroidism: decreased TSH, elevated free triiodothyronine, elevated FT4

blood lipids

Test
Result
Test

Screening for dyslipoproteinaemias/metabolic syndrome.

Result

elevated in dyslipidaemia, decreased in end-stage HF, especially in the presence of cardiac cachexia

Investigations to consider

serum ferritin

Test
Result
Test

For evaluation of cardiomyopathy due to iron overload cardiomyopathy/haemochromatosis.

Result

elevated (normal value 22-449 picomol/L [10-200 nanograms/mL])

transferrin saturation

Test
Result
Test

For evaluation of cardiomyopathy due to iron overload cardiomyopathy/haemochromatosis.

Result

elevated level of transferrin saturation; complete or almost complete transferrin saturation (normal transferrin saturation 22% to 46%)

non-invasive stress imaging (cardiovascular MRI, stress echocardiogram, SPECT, PET)

Test
Result
Test

To detect myocardial ischaemia and viability when underlying ischaemic heart disease is suspected.

Result

ischaemia, scar, viable myocardium

standard exercise stress testing (bicycle or treadmill)

Test
Result
Test

Provides an objective assessment of the patient's functional exercise limitation and haemodynamic response to exercise. Test is ordered when exercise-induced arrhythmias or ischaemia are suspected. Caution should be taken if there is a high likelihood for aortic stenosis or hypertrophic obstructive cardiomyopathy.

Result

usually reduced exercise capacity in idiopathic dilated cardiomyopathy; reduced exercise capacity and signs of impaired myocardial perfusion in ischaemic cardiomyopathy; however, functional capacity may be completely normal in patients with low left ventricular systolic function

coronary angiogram

Test
Result
Test

Provides assessment of coronary stenosis, and is particularly indicated in patients with HF and angina, ventricular tachycardia, or cardiac arrest. It is also done in patients with HF and ischaemia on non-invasive stress test.

Result

coronary artery disease/stenosis

cardiac CT angiography

Test
Result
Test

Its main use is in patients with HF who have low or intermediate pre-test probability of underlying coronary artery disease, or those with equivocal non-invasive stress tests.

In clinical practice it is also useful in patients with a clinical picture of stress/Takotsubo cardiomyopathy, in whom significant proximal coronary artery disease needs to be excluded as a cause of underlying presentation and echocardiogram findings.

Result

coronary artery disease/stenosis

cardiopulmonary exercise testing with VO₂ max

Test
Result
Test

Provides the most objective assessment of the patient's functional status.

Result

reduced VO₂ max

6-minute walking test exercise

Test
Result
Test

A patient with HF who cannot walk more than 300 m in 6 minutes has a substantially greater annual risk of death than one who can walk 450 m or more.

Result

as an alternative to cardiopulmonary exercise testing it may provide an objective assessment of the patient's functional status

right heart catheterisation

Test
Result
Test

Considered in patients intolerant to standard medical therapy, in whom medical therapy has failed to achieve symptomatic relief, before initiation of intravenous inotrope or inodilator therapy and in candidates for heart transplantation.

Result

provides objective haemodynamic assessment of left ventricular filling pressure and direct measures of cardiac output and pulmonary and systemic resistance

endomyocardial biopsy

Test
Result
Test

Ordered if acute myocarditis (giant cell or eosinophilic) or primary infiltrative diseases of the heart (amyloidosis, active cardiac sarcoidosis) suspected.

Result

rarely necessary to establish the aetiology of HF; provides definitive pathological evidence of cardiac and systemic disease, e.g., amyloidosis, sarcoidosis, myocarditis, iron overload cardiomyopathy

serum HIV enzyme-linked immunosorbent assay

Test
Result
Test

The majority of patients who have cardiomyopathy due to HIV do not present with symptoms of HF until other clinical signs of HIV infection are apparent.

Result

positive or negative

cardiac MRI

Test
Result
Test

Particularly useful in evaluation of conditions such as myocarditis, constrictive pericarditis, and infiltrative cardiomyopathy.

Result

myocarditis: sub-epicardial delayed enhancement in myocardium, high signal in myocardium in T2-weighted imaging; infiltrative cardiomyopathy: amyloid (global sub-endocardial delayed enhancement); sarcoid: (delayed enhancement); no sub-endocardial delayed enhancement; constrictive pericarditis: thick pericardium as well as diastolic septal bounce with inspiration

other biomarkers

Test
Result
Test

Troponin is helpful in further risk stratification in chronic HF, as elevated level is associated with progressive left ventricular dysfunction and increased mortality.​[102]

Soluble ST2 and galectin-3 (biomarkers for myocardial fibrosis) are predictive of death and hospitalisation in patients with HF and are additive to natriuretic peptide in their prognostic value.[103]​​

Result

borderline to minimally elevated

multi-slice computed tomography (MSCT)

Test
Result
Test

A method for left ventricular ejection fraction (LVEF) estimation. There appears to be no significant difference in LVEF estimation between MSCT and MRI, and also between MSCT and transthoracic echocardiogram.[104]

May offer additional benefit as it provides a combined evaluation of LVEF and coronary artery disease.

Result

quantifies LVEF and coronary artery disease

Use of this content is subject to our disclaimer