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Initial blood work should include CBC, electrolytes including calcium and magnesium, renal function studies, LFTs, fasting glucose, fasting lipid profile, iron studies (serum iron, ferritin, transferrin saturation) and TSH
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- Anemia or infection may cause HF; electrolytes may be abnormal due to fluid retention or renal dysfunction; liver dysfunction due to HF; lipid and TSH may reveal cardiovascular or thyroid disease as causes of HF.
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B-Type Natriuretic Peptide (BNP)
Normal < 100 pg/mL
N-terminal pro-B-type natriuretic peptide (NT- proBNP) Normal < 300 pg/ml
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- BNP and NT-proBNP are released by cardiac cells during myocardial stretch.
- Assist in screening of HF in patients at risk (HTN, diabetes, known vascular disease).
- Support diagnosis or exclusion of HF in patients presenting with dyspnea.
- Assist in prognosis in chronic HF, prognosis of acutely decompensated HF and post-discharge prognosis.
Note: Values may be increased by weight, age, in females, in acute stroke, severe sepsis or shock, subarachnoid hemorrhage or renal impairment.
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Biomarkers for myocardial infarction:
High Sensitivity Cardiac Troponin
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- When there is a suspicion of ACS, troponin may be used for risk stratification and to establish prognosis in acute decompensated HF.
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| Genetic testing |
- When a genetic or inherited cardiomyopathy is suspected, perform and diagram three generation family history. Consider genetic testing and/or genetic counseling in first-degree relatives of selected patients with genetic or inherited cardiomyopathies.
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| Urinalysis |
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| Chest X-ray |
- Assess heart size and pulmonary congestion; to detect other cardiac, pulmonary, or other diseases that may contribute to patient’s symptoms.
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| 12-lead ECG |
- Assess for left ventricular hypertrophy, MI, arrhythmias, heart blocks, and prolonged QT interval. The most useful initial test for evaluation of HF to assess left ventricular (LV) function, size, wall thickness, wall motion and valve function. Repeat EF measurement is useful in HF patients who have had a significant change in clinical status.
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| 2D Echocardiogram with Doppler |
- The most useful initial test for evaluation of HF to assess left ventricular (LV) function, size, wall thickness, wall motion and valve function. Repeat EF measurement is useful in HF patients who have had a significant change in clinical status.
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| Cardiac Computed Tomography |
- Provides assessment of cardiac structure and function, including coronary arteries.
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| Cardiac MRI |
- Useful to assess left ventricular ejection fraction (LVEF) and volume when echocardiography is inadequate and used to assess for infiltrative and inflammatory processes or scar burden.
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| Non-invasive testing to assess for ischemic disease (stress echocardiography, nuclear stress testing, PET cardiac stress testing, cardiac MRI) |
- May be used to assess for ischemia in HF patients who have known CAD or risk factors for CAD. Myocardial ischemia can contribute to new or worsening HF symptoms and non-invasive stress testing can help guide revascularization strategies.
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| Invasive Testing |
- Invasive hemodynamic evaluation (right heart catheterization) can be useful to guide management in patients with acute HF who have persistent symptoms despite treatment or when hemodynamics are unclear.
- Coronary angiography (left heart catheterization) may be useful in patients for definitive assessment of CAD and who are candidates for revascularization.
- Endomyocardial biopsy may be useful when seeking a specific diagnosis that would influence treatment and should also be considered in patients suspected of having acute cardiac rejection status after heart transplantation.
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| Wearable and Remote Monitoring |
- May be helpful to reduce recurrent hospitalization(s) in patients with NYHA Class III HF, a history of HF hospitalization in the past year on maximum tolerated doses of GDMT with optimal device therapy but further research is necessary to prove this end point.
- Strategies include an implantable pulmonary artery (PA) pressure sensor (CardioMEMS), noninvasive telemonitoring, or monitoring via existing implanted electronic devices.
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| NYHA Functional Class |
- Assess and document NYHA classification at baseline at time of initial diagnosis and after treatment through the continuum of care.
- NYHA functional classification is an independent predictor of mortality.
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| Cardiopulmonary Exercise Testing (CPET) |
- CPET is the gold standard measure of exercise capacity.
- In patients with unexplained dyspnea, CPET can help to distinguish respiratory versus cardiac etiologies of dyspnea, or if cardiopulmonary responses are normal, it can point other causes such as metabolic abnormalities and/or deconditioning.
- Limitations include lack of availability at many hospitals and clinics and not well tolerated by some patients.
- CPET is useful to risk stratify HF patients and to guide treatment decisions about timing of advanced HF therapies (e.g., heart transplantation and LVAD)
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| 6-Minute Walk Test |
- The 6-minute walk test is an alternative way to measure exercise capacity; it is widely available and well tolerated by patients.
- Prognosis can be predicted by total distance walked in the 6-minute walk test.
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