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Progressive Heart Failure –Etiopathogenesis, Invasive and 61
Noninvasive Evaluation

tion on etiology (e.g. myocardial infarction), and workup in case of initial evidence of HFpEF/
findings on the ECG might provide indications HFmrEF and consists of objective demon-
for therapy (e.g. anticoagulation for AF, pacing stration of structural and/or functional alter-
for bradycardia, CRT if broadened QRS complex) ations of the heart as the underlying cause
Therefore, the routine use of an ECG is mainly for the clinical presentation. Key structural
recommended to rule out HF. alterations are a left atrial volume index
(LAVI) >34 mL/m2 or a left ventricular mass
4. Chest x-ray: A chest X-ray is probably most use- index (LVMI) ≥115 g/m² for males and ≥95 g/m²
ful in identifying an alternative, pulmonary expla- for females.Key functional alterations are an
nation for a patient’s symptoms and signs. The E/e′≥13 and a mean e’ septal and lateral wall
chest X-ray may show pulmonary venous con- <9 cm/s. Other echocardiographically de-
gestion in a patient with HF, and is more helpful rived measurements are longitudinal strain
in the acute setting than in the non-acute setting. or tricuspid regurgitation velocity (TRV).
It is important to note that significant LV dysfunc-
tion may be present without cardiomegaly on the b) A diastolic stress test can be performed
chest X-ray. non-invasively with echocardiography, us-
ing a semi-supine bicycle ergometer with
5. Echocardiography:
assessment of rest and exercise-induced
a) Assessment of left ventricular systolic func- increases in E/e′, pulmonary artery pres-
tion:For measurement of LVEF, the modified sures (TRV), systolic dysfunction (longitudi-
biplane Simpson’s rule is the recommended nal strain), stroke volume and cardiac output
method. Three-dimensional echocardiogra- etc.
phy improves the quantification of LV vol-
umes and LVEF and has the best accura- c) Alternatively, cardiac catheterization can be
cy compared with values obtained through done to assesshemodynamics at rest and
CMR.Doppler techniques allow the calcula- exercise to assess filling pressures [pulmo-
tion of haemodynamic variables, such as nary capillary wedge pressure (PCWP) ≥15
stroke volume index and cardiac output, mmHg, left ventricular end diastolic pres-
based on the velocity time integral at the LV sure (LVEDP) ≥16 mmHg] pulmonary artery
outflow tract area. Tissue Doppler parame- systolic pressure, stroke volume and cardiac
ters, speckle tracking, 3D echo, stress Echo, output.
and deformation imaging techniques (strain d) Stress imaging (CMR, stress echo, SPECT,
and strain rate) have been shown to be of PET) in the assessment of myocardial isch-
more use, in detecting subtle abnormalities emia and viability in HF + CHD is given a
in systolic function in the preclinical stage. class IIb recommendation
b) Assessment of left ventricular diastolic func- f) Cardiac CT can be considered to rule-out
tion: LV diastolic dysfunction is thought to coronary arteries stenosis (class IIb)
be the underlying pathophysiological abnor- e) CMR plays a role in identifying the structural
mality in patients with HFpEF and perhaps and functional status of the myocardium. It
HFmrEF, and thus its assessment plays an can identify the myocardial edema fibrosis,
important role in diagnosis. The doppler flow viability and ischemia.
patterns of the AV valves, pulmonary, hepat-
ic and the venacavae, combined with tissue Diagnosis of HFpEF in patients with AF is difficult. AF
doppler imaging of the AV valve annular mo- by itself is associated with higher levels of NT-proB-
tion and AV valve flows, go a long way not NP or BNP. LAVI is also increased by AF A higher cut
only in assessing but also grading diastolic off values may be needed which however have not
dysfunction. Assessment of right ventricular been established. Other functional parameters of dia-
function and pulmonary arterial pressure is stolic dysfunction are less well established in AF. On
important in identifying and prognosticating the other hand, AF might be a sign of the presence of
progressive heart failure HFpEF and patients with HFpEF and AF might have
more advanced HF compared with patients with HF-
6. Advanced Work up in Progressive heart failure:
pEF and sinus rhythm.
a) Once progressive heart failure is suspect- Cardiac imaging thus plays a central role in the di-
ed the next step comprises an advanced
agnosis of HF and in guiding treatment. Of several

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