Browse the corpus

©2013 UpToDate ® Print Email ACC/AHA guideline summary: Initial evaluation of patients with heart failure (HF) Class I - There is evidence and/or general agreement that the initial evaluation of patients presenting with HF should include the following: • A complete history and physical examination to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. • A careful history of current and past use of alcohol, illicit drugs, standard or "alternative" therapies, and chemotherapy drugs. • An assessment of the ability to perform routine and desired activities of daily living. • An assessment of the volume status, orthostatic blood pressure changes, height and weight, and calculation of body mass index. • Laboratory studies including complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and serum thyroid-stimulating hormone. • A twelve-lead electrocardiogram and chest radiograph (posteroanterior and lateral). • Two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, wall thickness, and valve function. Radionuclide ventriculography can be performed to assess LVEF and volumes. • Coronary arteriography if there is a history or angina or significant ischemia unless the patient is not eligible for revascularization of any kind. Class IIa - The weight of evidence or opinion is in favor of benefit from performing the following studies as part of the initial evaluation of patients presenting with HF: • Coronary arteriography in patients who have chest pain that may or may not be of cardiac origin who have not had a prior evaluation of their coronary anatomy and are eligible for coronary revascularization. • Coronary arteriography in patients with known or suspected coronary artery disease who do not have angina and are eligible for revascularization. • Noninvasive imaging to detect myocardial ischemia and viability in patients with known or suspected coronary artery who do not have angina and are eligible for revascularization. • When the contribution of HF to exercise limitation is uncertain, maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation.

• Noninvasive imaging to detect myocardial ischemia and viability in patients with known or suspected coronary artery who do not have angina and are eligible for revascularization. • When the contribution of HF to exercise limitation is uncertain, maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation. • To identify candidates for cardiac transplantation or other advanced treatments, maximal exercise testing with measurement of respiratory gas exchange. • In selected patients, screening for hemochromatosis, sleep disturbed breathing, or human immunodeficiency virus (HIV) infection. • When suspected clinically, diagnostic tests for rheumatologic disease, amyloidosis, or pheochromocytoma. • Endomyocardial biopsy when a specific diagnosis is suspected that would influence therapy. • Measurement of serum B-type natriuretic peptide (BNP) in the urgent care setting if the clinical diagnosis of HF is uncertain. Measurement of natriuretic peptides (BNP and NT-proBNP) can be useful in risk stratification. Class IIb - The weight of evidence or opinion is less well established for the following testing in the initial evaluation of patients with HF • Noninvasive imaging to define the likelihood of coronary artery disease in patients with left ventricular dysfunction. • Holter monitoring in patients who have a history of myocardial infarction and are being considered for electrophysiologic study to document the inducibility of ventricular tachycardia. Class III - There is evidence and/or general agreement that the following tests are not useful or may be harmful in the initial evaluation of patients with HF • Routine endomyocardial biopsy in the absence of suspicion of a specific diagnosis that would influence therapy suspected. • Routine signal-averaged electrocardiography. • Routine measurement of serum neurohormones other than BNP (eg, norepinephrine or endothelin). Data from Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.