ECG

Look for:

• Abnormal rhythm
• QRS duration (relevant to consideration of cardiac resynchronization therapy (biventricular pacing))
• Evidence of LV hypertrophy (aortic valve disease? hypertrophic cardiomyopathy?)
• Pathological Q waves indicative of previous myocardial infarction
• Low QRS voltage (pericardial effusion? cardiac amyloidosis?)

Look for:

• Evidence of raised LA pressure
• Pleural effusion (may contribute to breathlessness)
• Pulmonary consolidation

Echocardiogram

Assess:

• LV size, geometry, regional and global systolic function, ejection fraction and diastolic function
• RV size and systolic function
• Estimated right atrial pressure (from inferior vena caval size and respiratory variation)
• Estimated pulmonary artery pressures
• Valve disease (present in 29% in EuroHeart Failure survey)
• Pericardial effusion

• For patients with suspected acute heart failure the optimal cut-points for excluding the diagnosis are:
  • BNP <100pg/mL (29pmol/L)
  • NT-pro-BNP <300pg/mL (35pmol/L)
• BNP/NT-pro-BNP may be lowered by obesity (body mass index >30) and by heart failure treatment.
• BNP/NT-pro-BNP may be raised in LV hypertrophy, COPD without RV dilatation, diabetes, age, liver cirrhosis, hypoxia of any cause, tachycardia.
• Raised plasma BNP/NT-pro-BNP with clinical features of heart failure in the presence of an apparently normal LV on echocardiography raises the possibility of diastolic heart failure, which is suggested by:
  • LV hypertrophy or left atrial dilatation
  • Diastolic dysfunction using echocardiographic indices (e.g. E' <9cm/s, E/E' ratio >15)

Sodium, potassium, urea and creatinine (including eGFR)

Albumin and liver function including INR (liver congestion)

Thyroid function

Full blood count

C-reactive protein if coexistent infection suspected

Glucose (undiagnosed diabetes common)

Plasma troponin if acute coronary syndrome possible