Diagnostic Testing and the Assessment of Heart Failure

  • Thenappan Thenappan
  • Allen S. Anderson
  • Savitri Fedson


Diagnosis of heart failure is being increasingly relied upon on advanced imaging technologies and diagnostic tests. A thorough history and a competent physical examination, followed by an electrocardiogram, basic laboratory studies, and an echocardiogram, remain a sound approach to the initial evaluation of heart failure. Echocardiography is the most useful diagnostic test readily available for the assessment of cardiac structure and function where as cardiac magnetic resonance imaging is the gold standard for the measurement of chamber volume, mass, and thereby ventricular systolic function. Measurement of BNP improves diagnostic accuracy, especially in the acute setting. Evaluation for coronary artery disease is critical. Invasive hemodynamic assessment is not routinely indicated in the diagnosis of heart failure but it is essential in patients being considered for advanced heart failure therapeutic options including cardiac transplantation or left ventricular assist device.


Biomarkers Echocardiography Cardiac MRI Hemodynamics Endomyocardial biopsy Impedance cardiography 


  1. 1.
    Hobbs FD, Davis RC, Lip GY. ABC of heart failure: heart failure in general practice. BMJ. 2000;​320(7235):626–9.PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Fedson S, Tsuang SW, Lewis EF, Nohria A, Givertz MM, Fang JC, Mudge GH, Stevenson LW. At risk for missed diagnosis of heart failure symptoms. J Card Fail. 2004;10(4:s8):S94.CrossRefGoogle Scholar
  3. 3.
    Bowles KR, Bowles NE. Genetics of inherited cardiomyopathies. Expert Rev Cardiovasc Ther. 2004;​2(5):683–97.CrossRefPubMedGoogle Scholar
  4. 4.
    Philbin EF, Dec GW, Jenkins PL, DiSalvo TG. Socioeconomic status as an independent risk factor for hospital readmission for heart failure. Am J Cardiol. 2001;87(12):1367–71.CrossRefPubMedGoogle Scholar
  5. 5.
    Spencer K, Anderson A, Bhargava A, et al. Physician performed point of care echocardiography using a laptop platform compared to physical examination in the cardiovascular patient. J Am Coll Cardiol. 2001;​37(8):2013–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Stevenson LW, Perloff JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA. 1989;261(6):884–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Butman SM, Ewy GA, Standen JR, Kern KB, Hahn E. Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension. J Am Coll Cardiol. 1993;22(4):968–74.CrossRefPubMedGoogle Scholar
  8. 8.
    Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41(10):1797–804.CrossRefPubMedGoogle Scholar
  9. 9.
    Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med. 2001;345(8):574–81.CrossRefPubMedGoogle Scholar
  10. 10.
    Davie AP, Francis CM, Love MP, et al. Value of the electrocardiogram in identifying heart failure due to left ventricular systolic dysfunction. Br Med J. 1996;​312(7025):222.CrossRefGoogle Scholar
  11. 11.
    Rahman JE, Helou EF, Gelzer-Bell R, et al. Noninvasive diagnosis of biopsy-proven cardiac amyloidosis. J Am Coll Cardiol. 2004;43(3):410–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Bristow M, Saxon L, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350(21):2140–50.CrossRefPubMedGoogle Scholar
  13. 13.
    Leier C, Cas L, Metra M. Clinical relevance and management of the major electrolyte abnormalities in congestive heart failure: hyponatremia, hypokalemia, and hypomagnesemia. Am Heart J. 1994;128(3):564–74.CrossRefPubMedGoogle Scholar
  14. 14.
    Fonarow G, Adams K, Abraham W, Yancy C, Boscardin W. Risk stratification for in-hospital mortality in acutely decompensated heart failure. JAMA. 2005;293(5):572–80.CrossRefPubMedGoogle Scholar
  15. 15.
    Anand I, McMurray JJ, Whitmore J, et al. Anemia and its relationship to clinical outcome in heart failure. Circulation. 2004;110(2):149–54.CrossRefPubMedGoogle Scholar
  16. 16.
    Swedberg K, Young JB, Anand IS, et al. Treatment of anemia with darbepoetin alfa in systolic heart failure. N Engl J Med. 2013;368(13):1210–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Krishnaswamy P, Lubien E, Clopton P, et al. Utility of B-natriuretic peptide levels in identifying patients with left ventricular systolic or diastolic dysfunction. Am J Med. 2001;111(4):274–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Lubien E, DeMaria A, Krishnaswamy P, et al. Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation. 2002;105(5):595–601.CrossRefPubMedGoogle Scholar
  19. 19.
    Maisel AS, McCord J, Nowak RM, et al. Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol. 2003;​41(11):2010–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Sagnella GA. Measurement and importance of plasma brain natriuretic peptide and related peptides. Ann Clin Biochem. 2001;38(Pt 2):83–93.CrossRefPubMedGoogle Scholar
  21. 21.
    Kelder JC, Cramer MJ, van Wijngaarden J, et al. The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. Circulation. 2011;124(25):2865–73.CrossRefPubMedGoogle Scholar
  22. 22.
    McMurray JJ, Adamopoulos S, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2012;14(8):803–69.CrossRefPubMedGoogle Scholar
  23. 23.
    Wang TJ, Larson MG, Levy D, et al. Impact of obesity on plasma natriuretic peptide levels. Circulation. 2004;109(5):594–600.CrossRefPubMedGoogle Scholar
  24. 24.
    van Veldhuisen DJ, Linssen GC, Jaarsma T, et al. B-type natriuretic peptide and prognosis in heart failure patients with preserved and reduced ejection fraction. J Am Coll Cardiol. 2013;61(14):1498–506.CrossRefPubMedGoogle Scholar
  25. 25.
    Sayama H, Nakamura Y, Saito N, Kinoshita M. Why is the concentration of plasma brain natriuretic peptide in elderly inpatients greater than normal? Coron Artery Dis. 1999;10(7):537–40.CrossRefPubMedGoogle Scholar
  26. 26.
    Redfield MM, Rodeheffer RJ, Jacobsen SJ, Mahoney DW, Bailey KR, Burnett Jr JC. Plasma brain natriuretic peptide concentration: impact of age and gender. J Am Coll Cardiol. 2002;40(5):976–82.CrossRefPubMedGoogle Scholar
  27. 27.
    Desai AS. Are serial BNP measurements useful in heart failure management? Serial natriuretic peptide measurements are not useful in heart failure management: the art of medicine remains long. Circulation. 2013;127(4):509–16; discussion 516.CrossRefPubMedGoogle Scholar
  28. 28.
    Januzzi JL, Troughton R. Are serial BNP measurements useful in heart failure management? Serial natriuretic peptide measurements are useful in heart failure management. Circulation. 2013;127(4):500–7; discussion 508.CrossRefPubMedGoogle Scholar
  29. 29.
    Felker GM, Hasselblad V, Hernandez AF, O’Connor CM. Biomarker-guided therapy in chronic heart failure: a meta-analysis of randomized controlled trials. Am Heart J. 2009;158(3):422–30.CrossRefPubMedGoogle Scholar
  30. 30.
    Porapakkham P, Zimmet H, Billah B, Krum H. B-type natriuretic peptide-guided heart failure therapy: a meta-analysis. Arch Intern Med. 2010;​170(6):​507–14.CrossRefPubMedGoogle Scholar
  31. 31.
    Horwich TB, Patel J, MacLellan WR, Fonarow GC. Cardiac troponin I is associated with impaired hemodynamics, progressive left ventricular dysfunction, and increased mortality rates in advanced heart failure. Circulation. 2003;108(7):833–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Sato Y, Yamada T, Taniguchi R, et al. Persistently increased serum concentrations of cardiac troponin t in patients with idiopathic dilated cardiomyopathy are predictive of adverse outcomes. Circulation. 2001;​103(3):369–74.CrossRefPubMedGoogle Scholar
  33. 33.
    Lok DJ, Van Der Meer P, de la Porte PW, et al. Prognostic value of galectin-3, a novel marker of fibrosis, in patients with chronic heart failure: data from the DEAL-HF study. Clin Res Cardiol. 2010;​99(5):323–8.PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Tang WH, Shrestha K, Shao Z, et al. Usefulness of plasma galectin-3 levels in systolic heart failure to predict renal insufficiency and survival. Am J Cardiol. 2011;108(3):385–90.PubMedCentralCrossRefPubMedGoogle Scholar
  35. 35.
    Guazzi M, Bandera F, Pelissero G, et al. Tricuspid annular systolic excursion and pulmonary systolic pressure relationship in heart failure: an index of right ventricular contractility and prognosis. Am J Physiol Heart Circ Physiol. 2013;305(9):H1373–81.CrossRefPubMedGoogle Scholar
  36. 36.
    Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiology. 2013; 62(16):e147–239.Google Scholar
  37. 37.
    Constantine G, Shan K, Flamm SD, Sivananthan MU. Role of MRI in clinical cardiology. Lancet. 2004;363(9427):2162–71.CrossRefPubMedGoogle Scholar
  38. 38.
    McCrohon JA, Moon JC, Prasad SK, et al. Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance. Circulation. 2003;108(1):54–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Rickers C, Wilke NM, Jerosch-Herold M, et al. Utility of cardiac magnetic resonance imaging in the diagnosis of hypertrophic cardiomyopathy. Circulation. 2005;​​112(6):855–61.CrossRefPubMedGoogle Scholar
  40. 40.
    Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. J Am Coll Cardiol. 2009;53(17):​1475–87.PubMedCentralCrossRefPubMedGoogle Scholar
  41. 41.
    Nakanishi R, Park HB, Arsanjani R, Berman DS, Min JK. Coronary CT angiography can be used as a substitute for coronary angiography in patients with significant LV dysfunction. Prog Cardiovasc Dis. 2013;​55(5):498–503.CrossRefPubMedGoogle Scholar
  42. 42.
    Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359(22):2324–36.CrossRefPubMedGoogle Scholar
  43. 43.
    Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52(21):1724–32.CrossRefPubMedGoogle Scholar
  44. 44.
    Shaw LJ, Hausleiter J, Achenbach S, et al. Coronary computed tomographic angiography as a gatekeeper to invasive diagnostic and surgical procedures: results from the multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: an International Multicenter) registry. J Am Coll Cardiol. 2012;60(20):2103–14.CrossRefPubMedGoogle Scholar
  45. 45.
    Sato A, Hiroe M, Nozato T, et al. Early validation study of 64-slice multidetector computed tomography for the assessment of myocardial viability and the prediction of left ventricular remodelling after acute myocardial infarction. Eur Heart J. 2008;29(4):​490–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Kalsch H, Lehmann N, Mohlenkamp S, et al. Association of coronary artery calcium and congestive heart failure in the general population: results of the Heinz Nixdorf Recall study. Clin Res Cardiol. 2010;99(3):175–82.CrossRefPubMedGoogle Scholar
  47. 47.
    Abunassar JG, Yam Y, Chen L, D’Mello N, Chow BJ. Usefulness of the Agatston score = 0 to exclude ischemic cardiomyopathy in patients with heart failure. Am J Cardiol. 2011;107(3):428–32.CrossRefPubMedGoogle Scholar
  48. 48.
    Klocke FJ, Baird MG, Bateman TM, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2003;42(7):1318–33.Google Scholar
  49. 49.
    Bonow RO. Radionuclide angiographic evaluation of left ventricular diastolic function. Circulation. 1991;​84(3 Suppl):I208–15.PubMedGoogle Scholar
  50. 50.
    Jacobson AF, Lombard J, Banerjee G, Camici PG. 123I-mIBG scintigraphy to predict risk for adverse cardiac outcomes in heart failure patients: design of two prospective multicenter international trials. J Nucl Cardiol. 2009;16(1):113–21.CrossRefPubMedGoogle Scholar
  51. 51.
    Verberne HJ, Brewster LM, Somsen GA, van Eck-Smit BL. Prognostic value of myocardial 123I-metaiodobenzylguanidine (MIBG) parameters in patients with heart failure: a systematic review. Eur Heart J. 2008;29(9):1147–59.CrossRefPubMedGoogle Scholar
  52. 52.
    Triposkiadis F, Karayannis G, Giamouzis G, Skoularigis J, Louridas G, Butler J. The sympathetic nervous system in heart failure physiology, pathophysiology, and clinical implications. J Am Coll Cardiol. 2009;54(19):1747–62.CrossRefPubMedGoogle Scholar
  53. 53.
    Ketchum ES, Jacobson AF, Caldwell JH, et al. Selective improvement in Seattle Heart Failure Model risk stratification using iodine-123 meta-iodobenzylguanidine imaging. J Nucl Cardiol. 2012;​19(5):1007–16.CrossRefPubMedGoogle Scholar
  54. 54.
    Stevenson LW. Tailored therapy before transplantation for treatment of advanced heart failure: effective use of vasodilators and diuretics. J Heart Lung Transplant. 1991;10(3):468–76.PubMedGoogle Scholar
  55. 55.
    Stevenson LW, Dracup KA, Tillisch JH. Efficacy of medical therapy tailored for severe congestive heart failure in patients transferred for urgent cardiac transplantation. Am J Cardiol. 1989;63(7):461–4.CrossRefPubMedGoogle Scholar
  56. 56.
    Binanay C, Califf RM, Hasselblad V, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005;294(13):1625–33.CrossRefPubMedGoogle Scholar
  57. 57.
    Costard-Jackle A, Fowler MB. Influence of preoperative pulmonary artery pressure on mortality after heart transplantation: testing of potential reversibility of pulmonary hypertension with nitroprusside is useful in defining a high risk group. J Am Coll Cardiol. 1992;19(1):48–54.CrossRefPubMedGoogle Scholar
  58. 58.
    Morgan JM, McCormack DG, Griffiths MJ, Morgan CJ, Barnes PJ, Evans TW. Adenosine as a vasodilator in primary pulmonary hypertension. Circulation. 1991;84(3):1145–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Ricciardi MJ, Knight BP, Martinez FJ, Rubenfire M. Inhaled nitric oxide in primary pulmonary hypertension: a safe and effective agent for predicting response to nifedipine. J Am Coll Cardiol. 1998;32(4):​1068–73.CrossRefPubMedGoogle Scholar
  60. 60.
    Bennett MK, Gilotra NA, Harrington C, et al. Evaluation of the role of endomyocardial biopsy in 851 patients with unexplained heart failure from 2000–2009. Circ Heart Fail. 2013;6(4):676–84.CrossRefPubMedGoogle Scholar
  61. 61.
    Vrana JA, Gamez JD, Madden BJ, Theis JD, Bergen 3rd HR, Dogan A. Classification of amyloidosis by laser microdissection and mass spectrometry-based proteomic analysis in clinical biopsy specimens. Blood. 2009;114(24):4957–9.CrossRefPubMedGoogle Scholar
  62. 62.
    Rosenberg P, Yancy CW. Noninvasive assessment of hemodynamics: an emphasis on bioimpedance cardiography. Curr Opin Cardiol. 2000;15:151–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • Thenappan Thenappan
    • 1
  • Allen S. Anderson
    • 2
  • Savitri Fedson
    • 3
  1. 1.Medicine-CardiologyUniversity of MinnesotaMinneapolisUSA
  2. 2.Division of Cardiology, Department of MedicineBluhm Cardiovascular Institute, Northwestern MedicineChicagoUSA
  3. 3.Department of MedicineUniversity of Chicago MedicineChicagoUSA

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