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An approach to diagnosis of heart failure

An approach to diagnosis of heart failure
This algorithm describes an approach to diagnosis of HF based upon a combination of clinical findings. This approach has not been validated and its sensitivity and specificity have not been determined.
HF: heart failure; LVEF: left ventricular ejection fraction; HFpEF: heart failure with preserved ejection fraction; DOE: dyspnea on exertion; PND: paroxysmal nocturnal dyspnea; JVD: jugular venous distention; S3: third heart sound; PMI: point of maximal impulse; AF: atrial fibrillation; LAE: left atrial enlargement; LVH: left ventricular hypertrophy; BNP: B-type natriuretic peptide; NT-proBNP: N-terminal pro-BNP; LA: left atrial; E: peak velocity of early left ventricular filling; A: peak velocity of late left ventricular filling; LVEDD: left ventricular end-diastolic dimension; e': peak early diastolic velocity of left ventricular myocardium adjacent to the mitral annulus; IVC: inferior vena cava; SPECT-MPI: single-photon emission computed tomography myocardial perfusion imaging; CMR: cardiovascular magnetic resonance; CT: computed tomography; PCWP: pulmonary capillary wedge pressure.
* HF symptoms include dyspnea, fatigue, and edema. Refer to the discussion of symptoms in UpToDate content on clinical manifestations and diagnosis of HF.
¶ In evaluating noncardiac causes, it is important to consider pulmonary causes. Pulmonary function tests may be helpful in evaluating respiratory symptoms. The presence of pulmonary disease does not exclude HF, as some patients have concurrent lung disease and HF. If the cause of dyspnea on exertion is uncertain, a cardiopulmonary exercise test may be helpful. For further details, refer to UpToDate content on cardiopulmonary exercise testing in the evaluation of dyspnea.
Δ If the LVEF cannot be adequately assessed by echocardiogram despite use of microbubble contrast agent, alternative methods for assessment include nuclear methods (radionuclide ventriculography and SPECT-MPI), CMR imaging, and cardiac CT. For further details, refer to UpToDate content on tests to evaluate LV function.
Evaluation in this setting varies depending upon clinical findings and suspected concurrent conditions such as ischemic heart disease. If a diagnosis of HF remains uncertain after noninvasive evaluation, a hemodynamic exercise test is the clinical gold standard for diagnosis of HF. If a hemodynamic exercise test is performed, PCWP ≥15 mmHg at rest or ≥25 mmHg during exercise is diagnostic for HF. Many patients with LVEF <50% without HF require guideline-directed therapy to reduce cardiovascular risk (particularly those with LVEF ≤40%, prior myocardial infarction, and/or hypertension). However, a diagnosis of HF has important therapeutic implications since some pharmacologic agents are indicated for HF and not for asymptomatic LV systolic dysfunction.
§ Refer to UpToDate content on determining the etiology and severity of HF or cardiomyopathy.
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