Diagnostics - Imaging

• Every patient with suspected new-onset HF (best initial imaging test to assess cardiac structure and function) [22][23]

• Changes in clinical features in patients receiving treatment (monitoring)

• Evaluation for device therapy

• Features of heart failure

  • Left ventricular systolic dysfunction: assessed via LVEF [1]

    • HFpEF: normal (50–70%)

    • Borderline HFpEF: (41–49%)

    • HFrEF: reduced (≤ 40%)

  • Diastolic dysfunction [24]

  • Pulmonary hypertension and right ventricular dysfunction

  • Pericardial and/or pleural effusion [25]

• Evidence of complications [24]

  • Cardiac dyssynchrony

  • Functional mitral regurgitation

  • Left atrial enlargement

• Underlying causes, including:

  • Regional wall motion abnormalities in coronary artery disease

  • Left ventricular hypertrophy in hypertension

  • Flow abnormalities across heart valves in valvular disease

acute, new-onset, or suspected heart failure

• Changes to cardiac silhouette

  • Enlarged: cardiothoracic width ratio > 0.5 [26]

  • Boot-shaped heart on PA view: RV enlargement

  • Signs of pericardial effusion (e.g., water bottle heart)

• X-ray findings of pulmonary congestion

• Signs of concurrent heart conditions, including:

  • Valvular calcifications in valvular disease

  • Pericardial calcification in constrictive pericarditis

• ECG signs of left ventricular hypertrophy (e.g., positive Sokolow-Lyon index)

• Left axis deviation

• ST-T abnormalities (e.g., ST depression)

• P wave abnormalities (e.g., P mitrale)

• Prolonged QTc interval

• Incomplete or complete left bundle branch block

• Ischemic changes of a previous or acute myocardial infarction (e.g., Q waves or ST elevations)

• Arrhythmias (e.g., atrial fibrillation, sinus tachycardia or bradycardia)

• Pericardial effusion (e.g., electrical alternans, low voltage QRS)

1. Advanced cardiac imaging (Cardiac MRI, Radionuclide ventriculography, PET myocardial perfusion imaging).

2. Other: Left heart catherization/ coronary angiogram, Right heart catheterization, Endomyocardial biopsy, blood pressure monitoring, ECG monitoring

• Gold standard for assessment of ventricular volume, mass, and ejection fraction

• Indications include:

  • Diagnostic uncertainty following echocardiography

  • Investigation of congenital heart disease or infiltrative processes

  • Determination of myocardial scar burden

used to assess LVEF and volume if other imaging modalities are inadequate or contraindicated

alternative noninvasive workup for suspected coronary artery disease

identification and treatment of coronary artery disease

• Assessment of right heart function and pulmonary vascular resistance in patients being considered for mechanical circulatory support or transplant

• Monitoring in cardiogenic shock: SvO2 will be low in decompensated heart failure.

indicated if there is ongoing diagnostic uncertainty in rapidly progressive disease or to confirm the diagnosis of infiltrative heart disease

Consider in patients with suspected hypertension.

Consider in suspected paroxysmal atrial fibrillation or other underlying arrhythmias.

Heart failure cells (hemosiderin-containing cells).

Consider in suspected paroxysmal atrial fibrillation or other underlying arrhythmias.