The strength of evidence (A, B, C) and strength of recommendations are defined at the end of the "Major Recommendations" field.

Evaluation of Patients at Risk

• Evaluation with a routine history, physical examination, chest X-ray, and electrocardiogram (ECG) is recommended in patients with the medical conditions or test findings listed in Table 4.1, below. (Strength of Evidence = B)

Table 4.1: Indications for Evaluation of Patients at Risk for Heart Failure (HF)

• Assessment of Cardiac Structure and Function. Echocardiography with Doppler is recommended to determine left ventricular (LV) size and function in patients without signs or symptoms suggestive of HF who have the risk factors listed in Table 4.2, below. (Strength of Evidence = B)

Table 4.2: Risk Factors Indicating the Need to Assess Cardiac Structure and Function in Patients at Risk for HF

• Determination of plasma B-type natriuretic peptide (BNP) or N-terminal (NT) pro-BNP concentration is not recommended as a routine part of the evaluation for structural heart disease in patients at risk but without signs and symptoms of HF. (Strength of Evidence = B)

Evaluation of Patients Suspected of Having HF

• Symptoms Consistent with HF. The symptoms listed in Table 4.3, below, suggest the diagnosis of HF. It is recommended that each of these symptoms be solicited and graded in all patients in whom the diagnosis of HF is being considered. (Strength of Evidence = B)

Table 4.3: Symptoms Suggesting the Diagnosis of HF

• Physical Examination. It is recommended that patients suspected of having HF undergo careful physical examination with determination of vital signs and be carefully evaluated for signs and symptoms shown in Table 4.4, below. (Strength of Evidence = C)

Table 4.4: Signs to Evaluate in Patients Suspected of Having HF

• It is recommended that BNP or NT-proBNP levels be assessed in all patients suspected of having HF when the diagnosis is not certain. (Strength of Evidence = B)
• Differential Diagnosis. The differential diagnoses in Table 4.5, below, should be considered as alternative explanations for signs and symptoms consistent with HF. (Strength of Evidence = C)

Table 4.5: Differential Diagnosis for HF Symptoms and Signs

Initial Evaluation of Patients with HF

• It is recommended that patients with a diagnosis of HF undergo evaluation as outlined in Table 4.6, below. (Strength of Evidence = C)

Table 4.6: Initial Evaluation of Patients with a Diagnosis of HF

• Symptoms. In addition to symptoms characteristic of HF, the following symptoms should be considered in the diagnosis of HF:
  • Angina
  • Symptoms of possible cerebral hypoperfusion, including syncope, presyncope, or lightheadedness
  • Symptoms suggestive of embolic events
  • Symptoms suggestive of sleep-disordered breathing
• Functional Capacity/Activity Level. It is recommended that the severity of clinical disease and functional limitation be evaluated and recorded and the ability to perform typical daily activities be determined. This evaluation may be graded by metrics such as New York Heart Association (NYHA) functional class (Table 4.7 in the original guideline document) (Strength of Evidence = A) or by the 6-minute walk test. (Strength of Evidence = C)
• Volume Status. The degree of volume excess is a key consideration during treatment. It is recommended that it be routinely assessed by determining:
  • Presence of paroxysmal nocturnal dyspnea or orthopnea
  • Daily weights and vital signs with assessment for orthostatic changes
  • Presence and degree of rales, S3 gallop, jugular venous pressure elevation, positive hepatojugular reflux, edema, and ascites (Strength of Evidence = B)
• Standard Laboratory Tests. It is recommended that the following laboratory tests be obtained routinely in patients being evaluated for HF: serum electrolytes, blood urea nitrogen, creatinine, glucose, calcium, magnesium, lipid profile (low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides), complete blood count, serum albumin, liver function tests, urinalysis, and thyroid function. (Strength of Evidence = B)
• ECG. It is recommended that all patients with HF have an ECG performed to:
  • Assess cardiac rhythm and conduction
  • Detect LV hypertrophy
  • Evaluate QRS duration, especially when ejection fraction < 35%
  • Detect evidence of myocardial infarction or ischemia (Strength of Evidence = B)
• Chest X-Ray. It is recommended that all patients with HF have a posteroanterior and lateral chest X-ray examination for determination of heart size, evidence of fluid overload, and detection of pulmonary and other diseases. (Strength of Evidence = B)
• Additional Laboratory Tests. It is recommended that patients with no apparent etiology of HF or no specific clinical features suggesting unusual etiologies undergo additional directed blood and laboratory studies to determine the cause of HF. (Strength of Evidence = C)
• Exercise testing is not recommended as part of routine evaluation in patients with HF. Specific circumstances in which maximal exercise testing with measurement of expired gases should be considered include:
  • Assessing disparity between symptomatic limitation and objective indicators of disease severity
  • Distinguishing non HF-related causes of functional limitation, specifically cardiac versus pulmonary
  • Considering candidacy for cardiac transplantation or mechanical intervention
  • Determining the prescription for cardiac rehabilitation
  • Addressing specific employment capabilities

  Exercise testing with physiologic testing for inducible abnormality in myocardial perfusion or wall motion abnormality should be considered to screen for the presence of coronary artery disease with inducible ischemia. (Strength of Evidence = C)

Common Errors in Initial Assessment

• Routine endomyocardial biopsy is not recommended in cases of new-onset HF. Endomyocardial biopsy should be considered in patients with rapidly progressive clinical HF or ventricular dysfunction, despite appropriate medical therapy. Endomyocardial biopsy also should be considered in patients suspected of having myocardial infiltrative processes, such as sarcoidosis or amyloidosis, or in patients with malignant arrhythmias out of proportion to LV dysfunction, where sarcoidosis and giant cell myocarditis are considerations. (Strength of Evidence = C)

Follow-up Evaluation

• It is recommended that clinical evaluation at each follow-up visit include determination of the elements listed in Table 4.9, below. (Strength of Evidence = B)

  These assessments should include the same symptoms and signs assessed during the initial evaluation. (Strength of Evidence = C)

Table 4.9: Elements to Determine at Follow-Up Visits of HF Patients

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