A direct comparison of recommendations presented in the above guidelines for the diagnosis and evaluation of chronic heart failure is provided below.
Areas of Agreement
Clinical Presentation/Assessment of Signs and Symptoms
There is overall agreement that the evaluation of patients with suspected HF focuses on interpretation of signs and symptoms, as they are what have led to consideration of the diagnosis and are the key to early detection. All of the groups stress the importance of taking a thorough history and careful physical examination, and agree that the physical examination should include observation, palpation, auscultation, and assessment of vital signs. The groups agree that the classic symptom of CHF is breathlessness (dyspnea). Other possible symptoms/signs include fatigue, orthopnea, PND, elevated JVP, third heart sound, lateral displacement of the apex beat, basal crepitations, ascites, and peripheral edema. There is overall agreement, however, that a purely clinical diagnosis is unreliable and problematic and that evaluation of cardiac structure and function using more objective tests is necessary to confirm the diagnosis, determine the cause of symptoms, and to evaluate the degree of underlying cardiac pathology.
Diagnostic Investigations
While the groups agree that the assessment of signs and symptoms plays an important role in the diagnosis of CHF, they further agree that diagnostic investigations aimed at assessing cardiac function are necessary to establish a diagnosis of CHF. All four groups recommend that patients with suspected CHF should receive a variety of basic tests, and that the specific tests to be performed will vary according to the clinical presentation. There is overall agreement, however, that the initial diagnostic workup will typically include a full blood count and urinalysis, as well as investigation of urea, electrolytes, creatinine, and glucose.
All of the groups recommend that a chest x-ray be performed in patients with suspected CHF to support a possible diagnosis of CHF and to investigate other potential causes of breathlessness. ESC, HFSA and NHFA/CSANZ also recommend an ECG be performed in every patient with suspected HF. There is overall agreement that if the ECG is normal, the diagnosis of heart failure is highly unlikely and alternative diagnoses should be considered. Refer to Areas of Difference below for the SIGN recommendations regarding ECG, as well as the four groups' recommendations for echocardiography. An additional routine investigation recommended by ESC is sampling of troponin I or T in suspected HF when the clinical picture suggests an acute coronary syndrome.
Other imaging modalities are addressed by ESC and NHFA/CSANZ. According to ESC, in patients in whom echocardiography at rest has not provided adequate information and in patients with suspected CAD, further non-invasive imaging may include CMRI, cardiac CT, or radionuclide imaging. NHFA/CSANZ notes that nuclear cardiology, stress echocardiography, and PET can be used to assess reversibility of ischemia and viability of myocardium in patients with CHF who have myocardial dysfunction and CHD. They add that protocols have been developed using MRI to assess ischemia and myocardial viability, and to diagnose infiltrative disorders.
With regard to cardiac catheterization, there is overall agreement between the groups that address it (ESC, HFSA, and NHFA/CSANZ) that it is not routinely indicated for the diagnosis and management of heart failure, but that it may be appropriate in patients with certain clinical presentations. ESC and NHFA/CSANZ agree that coronary angiography should be considered in HF patients with a history of exertional angina or suspected ischemic LV dysfunction. ESC also cites other instances in which coronary angiography would be appropriate. HFSA recommends coronary angiography be considered when pre-test probability of underlying ischemic cardiomyopathy is high and an invasive coronary intervention may be considered. An additional type of cardiac catheterization addressed by the groups is endomyocardial biopsy. There is overall agreement that it is helpful in the diagnosis of specific myocardial disorders. HFSA and NHFA/CSANZ cite specific instances in which myocardial biopsy may be appropriate.
Areas of Difference
ECG
While the other groups recommend ECG be performed in every patient with suspected heart failure, SIGN, in contrast, recommends that the patient undergo either an ECG or BNP test or (both depending on local circumstances) to determine the need for echocardiogram.
Echocardiography
While ESC and NHFA/CSANZ recommend an echocardiogram be performed in every patient with suspected HF in order to establish a diagnosis and determine the mechanism of heart failure, SIGN, in contrast, recommends it be performed only in patients who have either a raised BNP or NT-pro BNP level or abnormal ECG.
According to HFSA, selected groups of high-risk patients and patients with signs and symptoms of HF should undergo echocardiographic examination to assess cardiac structure and function. Included in this select group are patients with cardiomegaly, S3 gallop, or potentially significant heart murmurs detected during the physical examination.
Plasma BNP Measurement
All of the groups agree that measurement of plasma BNP or NT-pro BNP concentration has a high negative predictive value and can be valuable in the diagnostic workup of suspected CHF. While there is overall agreement that it is an appropriate investigation to be performed when the diagnosis is uncertain, HFSA is the only group to recommend that BNP or NT-pro BNP levels be assessed in all patients with suspected HF, especially when the diagnosis is uncertain. SIGN recommends that BNP testing be performed following the clinical examination and basic investigations, either alone or in addition to ECG, in order to determine the need for echocardiogram (they recommend echocardiography only in patients with raised BNP/NT-pro BNP levels and/or abnormal ECG). SIGN also states that in the assessment of suspected HF, BNP or NT-pro BNP levels should ideally be checked on samples taken prior to commencing therapy.
