Heart failure learning module 2: diagnosis

Released1 November 2017     Expires: 01 November 2019      Programme:

Other imaging modalities

Other imaging techniques can be helpful.1,21

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Cardiac catheterisation and coronary angiography

This is indicated in the following clinical scenarios:

  • heart failure caused by systolic dysfunction in association with angina with regional wall motion abnormalities and/or scintigraphic evidence of reversible myocardial ischaemia when revascularisation is being considered
  • ‘work-up’ for cardiac transplantation
  • heart failure secondary to complications of MI such as ventricular aneurysm.
Nuclear imaging

Nuclear imaging, including ECG-gated myocardial perfusion imaging can be used to assess heart function and damage in heart failure. ECG-gated single-photon emission CT (SPECT) can be used to assess global LVEF, regional wall motion abnormalities, and regional wall thickening. If coronary artery disease is suspected CT (SPECT) can also assess for ischaemia and myocardial viability.

Cardiac computed tomography (CT) scanning of the heart is not usually required in the routine diagnosis and management of heart failure. Multidetector CT (MDCT) scanning is useful in delineating congenital and valvular abnormalities; however, echocardiography and CMR may provide similar information without exposing the patient to ionising radiation.

Positron emission tomography (PET) (alone or with CT) may also be used to assess ischaemia and viability,but lack of availability, radiation exposure, and wide availability of cheaper alternatives limit its’ use.

Imaging summary statement

Appropriate and timely imaging is crucial in a patient with suspected heart failure; it can make a diagnosis, reveal an underlying cause, guide therapy and predict outcome.

Echocardiography remains the primary investigation due to its widespread availability, low cost and wealth of clinical experience. CMR, however, is also a powerful imaging modality in heart failure which may give more information as to the aetiology of the condition.

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References

1. Remes J, Miettinen H, Reunanen A, Pyorala K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J 1991;12:315–21

2. Collins SP, Lindsell CJ, Peacock WF, Eckert DC, Askew J, Storrow AB. Clinical characteristics of emergency department heart failure patients initially diagnosed as non-heart failure. BMC Emerg Med 2006;6:11 http://dx.doi.org/10.1186/1471-227X-6-11

3. van Riet EE, Hoes AW, Limburg A, Landman MA, van der Hoeven H, Rutten FH. Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion. Eur J Heart Fail 2014;16(7):772-7 http://dx.doi.org/10.1002/ejhf.110

4. Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003;289(2):194-202 http://dx.doi.org/10.1001/jama.289.2.194

5. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail 2016;18:891–975. http://dx.doi.org/10.1002/ejhf.592

6. National Institute for Health and Care Excellence CG108. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. London: NICE, 2010. Available from www.nice.org.uk/cg108 [Accessed 10th May 2017]

7. McDonagh TA, Gardner RS, Clark AL, Dargie H (eds). Oxford Textbook of Heart Failure. Oxford University Press. July 2011. http://dx.doi.org/10.1093/med/9780199577729.001.0001

8. Clark AL, Coats AJS. Unreliability of cardiothoracic ratio as a marker of left ventricular impairment: comparison with radionuclide ventriculography and echocardiography. Postgrad Med J 2000;76:289–91 http://dx.doi.org/10.1136/pmj.76.895.289

9. Raphael C, Briscoe C, Davies J et al. Limitations of the New York Heart Association functional classification system and self-reported walking distances in chronic heart failure. Heart 2007;93:476–82 http://dx.doi.org/10.1136/hrt.2006.089656

10. Goldman L, Hashimoto B, Cook EF, Loscalzo A. Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale. Circulation 1981;64:1227–34 https://doi.org/10.1161/01.CIR.64.6.1227

11. American Thoracic Society Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: Guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;166:111–7 https://doi.org/10.1164/ajrccm.166.1.at1102

12. Roul G, Germain P, Bareiss P, et al. Does the 6-minute walk test predict the prognosis in patients with NYHA class II or III chronic heart failure? Am Heart J 1998;136:449–57http://dx.doi.org/10.1016/S0002-8703(98)70219-4

13. Abraham WT, Adamson PB, Bourge RC, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet 2011;377:658–66. http://dx.doi.org/10.1016/S0140-6736(11)60101-3

14. Bourge RC, Abraham WT, Adamson PB, et al. Randomized controlled trial of an implantable continuous hemodynamic monitor in patients with advanced heart failure: the COMPASS-HF study. J Am Coll Cardiol 2008;51:1073–9. http://dx.doi.org/10.1016/j.jacc.2007.10.061

15. Antony R, Daghem M, McCann GP, et al. Cardiovascular magnetic resonance activity in the United Kingdom: a survey on behalf of the British Society of Cardiovascular Magnetic Resonance. J Cardiovasc Magn Reson 2011;13:57. http://dx.doi.org/10.1186/1532-429X-13-57

16. Bruder O, Schneider S, Nothnagel D, et al. EuroCMR (European Cardiovascular Magnetic Resonance) registry: results of the German pilot phase. J Am Coll Cardiol 2009;54:1457–66. http://dx.doi.org/10.1016/j.jacc.2009.07.003

17. Assomull RG, Shakespeare C, Kalra PR, et al. Role of cardiovascular magnetic resonance as a gatekeeper to invasive coronary angiography in patients presenting with heart failure of unknown etiology. Circulation 2011;124:1351–60. http://dx.doi.org/10.1161/​CIRCULATIONAHA.110.011346

18. Carson P, Wertheimer J, Miller A, et al.The STICH Trial (Surgical Treatment for Ischemic Heart Failure). JCHF 2013;1:400–8. http://dx.doi.org/10.1016/j.jchf.2013.04.012

19. Velazquez EJ, Lee KL, Jones RH et al. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med 2016; 374(16):1511-20 http://dx.doi.org/10.1056/NEJMoa1602001

Further reading

Yu CM, Sanderson JE, Gorcsan J. Echocardiography, dyssynchrony and the response to cardiac resynchronization therapy. Eur Heart J 2010;19:2326–37. http://dx.doi.org/10.1093/eurheartj/ehq263

Shah BN, Khattar RS, Senior R. The hibernating myocardium: current concepts, diagnostic dilemmas and clinical challenges in the post-STICH era. Eur Heart J 2013:34:1323–36. http://dx.doi.org/10.1093/eurheartj/eht018

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Healthcare professionals should consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews (Cardiology) Limited cannot accept responsibility for any errors in prescribing which may occur.

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All rights reserved. No part of this programme may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publishers, Medinews (Cardiology) Limited.

It shall not, by way of trade or otherwise, be lent, re-sold, hired or otherwise circulated without the publisher’s prior consent.

Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs becomes necessary. The editors/authors/contributors and the publishers have taken care to ensure that the information given in this text is accurate and up to date. Readers are strongly advised to confirm that the information, especially with regard to drug usage, complies with the latest legislation and standards of practice.

Healthcare professionals should consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews (Cardiology) Limited cannot accept responsibility for any errors in prescribing which may occur.