Obligatory medical device diagnostics in acute heart failure.
- Echocardiography (echo; cardiac ultrasound) – either transthoracic (“through the chest (thorax)”) or transesophageal (TEE; “through the esophagus (esophagus)”) [to assess left ventricular ejection fraction (LVEF; pump function) and its wall thickness; Doppler-assisted examination for vitia (heart valve defects); estimation of pulmonary arterial pressure; exclusion or Detection of intracardiac thrombi/blood clots in the heart]
- Electrocardiogram (ECG; recording of electrical activity of the heart muscle; resting 12-lead ECG).
- Possible presenting findings: ST-segment elevations; ST-segment depressions; new T wave; atrial fibrillation.
- QRS interval > 120 ms – increased mortality or rehospitalization rate within ten months.
- X-ray of the chest (X-ray thorax/chest), in two planes – to detect:
- Myocardial enlargement (enlarged cardiothoracic quotient, normal finding: < 0.5; cardiomegaly? Dilatation?)
- Pulmonary congestion (pulmonary congestion) with:
- Short, horizontal Kerley B lines (lines that run in the lower lung segments near the thoracic wall at the so-called costophrenic angle; predominantly on the right side)
- Symmetrical perihilar (“around the pulmonary pedicle”) consolidation and possibly a dilated V. azygos
- Blood oxygen saturation (pulse oximetry; measurement of oxygen saturation (SpO2) of arterial blood and pulse rate).
- Lung ultrasonography (synonyms: lung ultrasound; Engl. Lung ultrasonography, LUS) – evidence of pulmonary venous congestion/congestion of the pulmonary veins [evidence of B-lines: interstitial fluid accumulation (in the interstitial spaces) caused by blood reflux; congestion lung: When total number of B-lines in eight thoracic regions/chest regions (four per side) is three or more]LUS-guided heart failure therapy results in a significantly lower risk of needing emergency medical attention than standard care without LUS.
Optional medical device diagnostics – depending on the results of the history, physical examination, laboratory diagnostics and obligatory medical device diagnostics – for differential diagnosis.
- Cardiac catheterization – for suspected acute coronary syndrome (AKS or ACS, acute coronary syndrome; spectrum of cardiovascular disease ranging from unstable angina (iAP; UA) to the two main forms of myocardial infarction (heart attack), non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI)).
- Computed tomography of the thorax/chest (chest CT) – to assess heart size/pulmonary vascular drawing.
Mandatory medical device diagnostics in chronic heart failure.
- Echocardiography (echo; cardiac ultrasound) – either transthoracic or transesophageal [echocardiographic assessment of ejection fraction (pump function):
- HFrEF: “heart failure with reduced ejection fraction”; heart failure with reduced ejection fraction (= systolic heart failure; synonym: isolated systolic dysfunction; systole is the tense and thus blood outflow phase of the heart)
- Decrease in left ventricular ejection fraction (LVEF <40% = “heart failure with reduced ejection fraction” (HFrEF)) with increased left ventricular end-diastolic pressure and volume (LVEDP and LVEDV)
- HFmrEF: “Heart Failure mid-range Ejection Fraction”; “mid-range” heart failure [approximately 10-20% of patients]:
- LVEF 40-49%
- Increased serum natriuretic peptide concentration (BNP > 35 pg/ml and/or NT-proBNP > 125 pg/ml); and
- Echocardiographic evidence of relevant structural heart disease (LVH and/or LAE) and/or diastolic dysfunction (see below * ).
- HFpEF: “Heart Failure with preserved Ejection Fraction”; heart failure with preserved ejection fraction (= diastolic heart failure; synonym: diastolic dysfunction; diastole is the slackening and thus blood inflow phase); this is defined as:
- LVEF: ≥ 50%= decreased distensibility (compliance) predominantly of the left ventricle of the heart with normal systolic pump function.
- Increased serum natriuretic peptide concentration (BNP > 35 pg/ml and/or NT-proBNP > 125 pg/ml).
- Echocardiographic evidence of relevant structural heart disease (LVH and/or LAE) and/or diastolic dysfunction (see below * ).
* Here, the guidelines call for multiple parameters representing structural changes of the heart to be critical for diagnosis:
- Enlargement of the left atrium (and, if necessary, consecutive right atrial cavities).
- LV hypertrophy and, in particular, alteration of the Doppler sonographic profile over the mitral valve with
- Increase in E:A ratio to >2 (“restrictive filling profile over the mitral valve“).
- Drop in e’ to < 9 cm/s and increase in E:e’ ratio to > 13 (value: < 8 is considered normal)]
- HFrEF: “heart failure with reduced ejection fraction”; heart failure with reduced ejection fraction (= systolic heart failure; synonym: isolated systolic dysfunction; systole is the tense and thus blood outflow phase of the heart)
- Electrocardiogram (ECG; recording of the electrical activity of the heart muscle).
- Stress ECG
- X-ray of the chest (chest x-ray/chest x-ray), in two planes – to detect myocardial enlargement/cardiac muscle enlargement (dilatation? ), pulmonary congestion or pulmonary edema (water accumulation in the lungs)
Legend
- LVEF: left ventricular ejection fraction; ejection fraction (also expulsion fraction) of the left ventricle during a heartbeat.
- LAE: enlargement of the left atrium (left atrial volume index [LAVI] > 34 ml/m2.
- LVH: left ventricular hypertrophy (left ventricular muscle mass index [LVMI] ≥ 115 g/m2 for men and ≥ 95 g/m2 for women).
Optional medical device diagnostics-depending on the results of the history, physical examination, laboratory diagnostics, and obligatory medical device diagnostics-for differential diagnostic clarification.
- Breath shock test or spirometry (basic examination in the context of pulmonary function diagnostics) – to delineate extracardiac causes of dyspnea (noncardiac respiratory symptoms).
- Positron emission tomography (PET; nuclear medicine procedure that allows the creation of cross-sectional images of living organisms by visualizing the distribution patterns of weak radioactive substances) – for the study of myocardial activity (heart muscle activity).
- Single-photon emission tomography (SPECT; functional imaging method of nuclear medicine, with which, based on the principle of scintigraphy, sectional images of living organisms can be created) – for the study of myocardial activity.
- Cardiac catheterization – for suspected myocardial ischemia (circulatory disorder of the heart muscle).
- Computed tomography of the thorax/chest (thoracic CT) – to assess heart size/pulmonary vascular drawing.
- Cardio-magnetic resonance imaging (cardio-MRI; cMRI) – captures not only cardiac mechanical parameters but much of the underlying pathology (microvascular dysfunction, diffuse fibrosis, altered filling, and altered vascular stiffness)
Ejection fraction as an indicator of heart failure
According to a study based on a review of 13 publications with data from more than 25,000 initially asymptomatic study participants followed for a mean of approximately 8 years, the risk of developing symptomatic heart failure in patients with systolic dysfunction is 4.6 times higher in those with diastolic dysfunction 1.7 times higher than in heart-healthy individuals.
