Initial and Serial Clinical Assessment of Patients Presenting With Heart Failure
Class I
(1) A thorough history and physical examination should be obtained/ performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF
(2) A careful history of current and past use of alcohol, illicit drugs, current or past standard or “alternative therapies,” and chemotherapy drugs should be obtained from patients presenting with HF.
(3) In patients presenting with HF, initial assessment should be made of the patient’s ability to perform routine and desired activities of daily living.
(4) Initial examination of patients presenting with HF should include assessment of the patient’s volume status, orthostatic blood pressure changes,measurement of weight and height, and calculation of body mass index.
(5) Initial laboratory evaluation of patients presenting with HF should include 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 thyroid-stimulating hormone.
(6) Twelve-lead electrocardiogram and chest radiograph (posterior- anterior and lateral) should be performed initially in all patients presenting with HF.
(7) Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess LVEF, left ventricular size, wall thickness, and valve function. Radionuclide ventriculography can be performed to assess LVEF and volumes.
(8) Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind.
Class IIa
(1) Coronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary revascularization.
(2) Coronary arteriography is reasonable for patients presenting with HF who have known or suspected coronary artery disease but who do not have angina unless the patient is not eligible for revascularization of any kind.
(3) Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with HF who have known coronary artery disease and no angina unless the patient is not eligible for revascularization of any kind.
(4) Maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation is reasonable in patients presenting with HF to help determine whether HF is the cause of exercise limitation when the contribution of HF is uncertain.
(5) Maximal exercise testing with measurement of respiratory gas exchange is reasonable to identify high-risk patients presenting with heart failure who are candidates for cardiac transplantation or other advanced treatments.
(6) Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected patients who present with HF.
(7) Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases.
(8) Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy
(9) Measurement of natriuretic peptides (BNP and NT-proBNP) can be useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. Measurement of natriuretic peptides (BNP and NT-proBNP) can be helpful in risk stratification
Class IIb
(1) Noninvasive imaging may be considered to define the likelihood of coronary artery disease in patients with HF and LV dysfunction.
(2) Holter monitoring might be considered in patients presenting with HF who have a history of MI and are being considered for electrophysiologic study to document VT inducibility.
Class III
(1) Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF.
(2) Routine use of signal-averaged electrocardiography is not recommended for the evaluation of patients presenting with HF.
(3) Routine measurement of circulating levels of neurohormones (e.g., norepinephrine or endothelin) is not recommended for patients presenting with HF.
JACC. 2009; 53; e1-e90