1st-order laboratory parameters-obligatory laboratory tests.
- Blood count (Hb < 9 g/dL – worse prognosis).
- Inflammatory parameters – CRP (C-reactive protein), preferably using a highly sensitive measurement method (hs-CRP) or ESR (erythrocyte sedimentation rate).
- Urine status (rapid test for: pH, leukocytes, nitrite, protein, glucose, ketone, blood), sediment, if necessary urine culture (pathogen detection and resistogram, that is, testing of suitable antibiotics for sensitivity / resistance).
- Electrolytes (sodium, potassium): [baseline and progression diagnostic]
- Sodium (estimation of the extent of neurohormonal activation; sodium concentration is inversely proportional to renin; sodium concentration is a prognostic factor).
- Potassium should be between 4-5 mmol/l; poorer prognosis at: Potassium concentration < 4 nmol/l
- Fasting glucose (fasting blood glucose), if necessary oral glucose tolerance test (oGTT).
- Liver parameters – alanine aminotransferase (ALT, GPT), aspartate aminotransferase (AST, GOT), glutamate dehydrogenase (GLDH) and gamma-glutamyl transferase (gamma-GT, GGT), alkaline phosphatase, bilirubin.
- Renal parameters – urea, creatinine, cystatin C or creatinine clearance as appropriate – worsening ventricular function is associated with increasing creatinine. [baseline and follow-up diagnostics.]
- NT-proBNP (N-terminal pro brain natriuretic peptide) – for diagnosis of heart failure as well as progression, therapy and prognosis monitoring.
- NT-pro-BNP can be used to clarify whether or not heart failure (cardiac insufficiency) is present. NT-proBNP is synthesized by cardiac myocytes primarily as a result of stretch stimuli and neurohumoral stimulation and released into the bloodstream. In patients with NT-proBNP levels below 125 pg/ml, left ventricular dysfunction – dysfunction of the left ventricle – can be ruled out despite the presence of suspected symptoms, e.g., dyspnea (shortness of breath)! Also, NT-pro-BNP levels increase significantly with increasing severity of heart failure.Correlation between NT-proBNP and stage of heart failure (NYHA/New York Heart Association, median/95th percentile):
- NYHA I: 342/3,410 ng/l [= pg/ml]
- NYHA II: 951 / 6,567 ng/l
- NYHA III: 1,571 / 10,449 ng/l
- NYHA IV: 1,707 / 12,188 ng/l
- Exclusion of ventricular dysfunction: NT-proBNP < 125 ng/l
- Exclusion of acute heart failure: NT-proBNP < 300 pg/ml (BNP < 100 pg/ml or MR-proANP < 120 pg/ml).
- NT-proBNP can be reliably and accurately determined in both serum and plasma. It is not subject to diurnal rhythms, can be determined under normal blood sampling, and the patient does not need to follow any special dietary restrictions.
- False positive values can be due to age, thyroid function and kidney function.
- Elevated values require further diagnosis by echocardiography (echo; heart ultrasound).
- NT-pro-BNP can be used to clarify whether or not heart failure (cardiac insufficiency) is present. NT-proBNP is synthesized by cardiac myocytes primarily as a result of stretch stimuli and neurohumoral stimulation and released into the bloodstream. In patients with NT-proBNP levels below 125 pg/ml, left ventricular dysfunction – dysfunction of the left ventricle – can be ruled out despite the presence of suspected symptoms, e.g., dyspnea (shortness of breath)! Also, NT-pro-BNP levels increase significantly with increasing severity of heart failure.Correlation between NT-proBNP and stage of heart failure (NYHA/New York Heart Association, median/95th percentile):
- Highly sensitive cardiac troponin T (hs-cTnT) or troponin I (hs-cTnI).
- In suspected acute decompensated heart failure as a baseline diagnostic test.
- In case of suspected myocardial infarction (heart attack)
- also appears to assess the risk of future heart failure in advance (screening):
- The 10-year rate of heart failure was 13.2% in individuals with hs-cTnI values ≥ 3.2 ng/l and NT-proBNP values ≥ 68.26 ng/l.
- Optimal hs-cTnI cutoff values for selection of high-risk individuals were found to be 4.2 ng/l (for men) and 2.6 ng/l (for women).
Laboratory parameters 2nd order – depending on the results of the history, physical examination, etc. – for differential diagnostic clarification.
- TSH (thyroid stimulating hormone) – clarification of hyperthyroidism (hyperthyroidism) or hypothyroidism (hypothyroidism).
- D-dimers – To exclude a pulmonary artery embolism (LAE).
- If central venous pressure increases > 10 mmHg or cardiac index < 1.5 l/min/m2, liver parameters are elevated:
- Blood sedimentation and blood culture or blood cultures – if endocarditis (endocarditis) is suspected.
- Ferritin – if iron deficiency anemia (anemia due to iron deficiency) is suspected.
- Ferritin and transferrin saturation – if hemochromatosis is suspected.
- Total protein and albumin – indication of kidney or liver disorders.
- Myocardial biopsy – all patients with etiologically unclear heart failure (with VD on myocarditis/heart muscle inflammation) must be clarified myocardial biopsy!
Laboratory parameters – for follow-up of drug therapy (before therapy, one to two weeks after each dose increase, after three months, then at six-month intervals; if therapy is changed; during each hospitalization). [Beta-receptor blockers: not affected; ivabradine: renal retention values only].
- Electrolytes (sodium, potassium).
- Renal retention values (esp. creatinine) in serum or GFR estimated with it.
Note on heart failure (HI) with preserved left ventricular ejection fraction, HFpEF.
- Risk assessment and prognostic prediction of patients with this specific form of heart failure is improved by CRP (C-reactive protein), a biomarker of general inflammatory events measured by a highly sensitive measurement method (hsCRP). In this specific patient group, a combined measurement of hs-CRP and the biomarker NT-pro-BNP (see above), which is well established in the diagnosis of HI, is clearly superior to a sole measurement of NT-pro-BNP.
Laboratory constellations in cardiac-induced hepatopathies (modified from).
| Laboratory parameters | Acute heart failure | Chronic heart failure |
| GGT/AP | + | + |
| AST; GOT/ALT, GPT | +++/++ | (+) |
| Bilirubin | + | + |
| GLDH | (+) | ++++ |
| LDH | (+) | +++ |
| BNP/NT-proBNP | +++/++++ | +/++ |
Legend
- ALT: alanine aminotransferase (GPT).
- AST: aspartate aminotransferase (GOT)
- AP: alkaline phosphatase
- BNP: brain natriuretic peptide
- GGT γ-glutamyltransferase
- GLDH: glutamate dehydrogenase
- LDH: lactate dehydrogenase
Evidence of cholestasis
- Only mild transaminase elevation; however, AP and gamma-GT are often elevated more than three- to fivefold, with gamma-GT proving to be the more sensitive parameter.
- No meaningful conclusions can be drawn from the level of serum bilirubin.
- A high AP compared to bilirubin usually indicates infiltrative processes, in this case LDH also usually increases.
