Diagnosing Congestive Heart Failure

Clinical Assessment

The American College of Cardiology and the American Heart Association recommend documenting current symptoms, such as dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and fatigue that limits exercise tolerance, to assess the severity of heart failure 1, 2, 5
The American College of Cardiology recommends quantifying functional capacity by determining the patient's ability to perform routine and desired activities of daily living 1, 2, 3
Identifying risk factors and causes, such as coronary artery disease, hypertension, diabetes, valvular disease, prior myocardial infarction, and family history of cardiomyopathy, is crucial in diagnosing heart failure 2
A substance exposure history, including current and past alcohol use, illicit drugs, chemotherapy agents, and alternative therapies, should be obtained to assess potential reversible causes of heart failure 1, 2, 3, 5

The American College of Cardiology recommends performing a 12-lead ECG to identify arrhythmias, conduction abnormalities, left ventricular hypertrophy, or evidence of prior MI, with a completely normal ECG having >90% negative predictive value for excluding LV systolic dysfunction 1, 2, 3, 6, 7, 8
A chest X-ray (PA and lateral) should be obtained to assess for cardiomegaly, pulmonary venous congestion, interstitial edema, pleural effusions, and Kerley B lines, although cardiomegaly may be absent even in chronic heart failure 1, 2, 3, 7, 8
Two-dimensional echocardiography with Doppler is the definitive diagnostic test and must be performed in all patients to assess left ventricular ejection fraction (LVEF), LV size, wall thickness, regional wall motion abnormalities, and valve function 1, 2, 3, 4, 6, 7, 8
Laboratory testing, including complete blood count, comprehensive metabolic panel, and natriuretic peptides (BNP or NT-proBNP), should be performed to evaluate renal function, detect anemia, and guide further evaluation 1, 2, 3, 4, 6, 7

The American College of Cardiology recommends an algorithmic approach to diagnosing heart failure, including initial triage, clinical probability assessment, natriuretic peptide interpretation, and echocardiographic confirmation 4, 6
Natriuretic peptides (BNP or NT-proBNP) should be measured when clinical diagnosis is uncertain, with low levels (NT-proBNP <300 pg/mL or BNP <100 pg/mL) indicating heart failure is unlikely, and elevated levels prompting further evaluation with echocardiography 4, 6, 7, 8

The American College of Cardiology recommends coronary arteriography in patients with angina or significant ischemia, unless not eligible for revascularization 1, 2, 3
Noninvasive ischemia testing is reasonable in patients with known CAD and no angina to detect myocardial ischemia and viability 2, 3, 5

Maximal exercise testing with or without respiratory gas exchange measurement may be performed when HF contribution to exercise limitation is uncertain, or to identify high-risk patients for transplant evaluation 2, 4, 5
Screening tests, such as hemochromatosis, sleep-disturbed breathing, HIV, rheumatologic diseases, amyloidosis, and pheochromocytoma, should be considered when clinically suspected 4, 5, 7
Endomyocardial biopsy may be useful when a specific diagnosis is suspected that would influence therapy, but should not be performed routinely 4
Advanced imaging (cardiac MRI or CT) may be considered when echocardiography is inconclusive or technically limited, particularly for detecting myocardial fibrosis or infiltrative diseases 8