It is of utmost importance that a diagnosis should be established – and appropriate treatment initiated as soon as possible – in patients presenting with signs and symptoms of acute heart failure. In fact, it is recommended that diagnosis and identification of precipitants should occur in parallel with treatment (Shah et al., 2017). Since the symptoms and signs may be non-specific or not sensitive, the diagnosis of acute heart failure must preferably be confirmed by the following investigations (Ponikowski et al., 2016):

  • chest X-ray in the upright position (supine chest X-ray is of limited value in this setting) to confirm pulmonary venous congestion. It can also help to identify any pleural effusion
  • electrocardiogram. The ECG is seldom normal in acute heart failure, and it can aid in identifying concomitant cardiac diseases
  • echocardiography is helpful to assess the contractile function of the ventricles
  • measurement of plasma levels of B-type natriuretic peptides (BNPs) and N-terminal pro-B type natriuretic peptides (NT-proBNPs). In the acute setting higher threshold levels have been suggested as a diagnostic tool to identify patients requiring further cardiac investigation; BNP <100 pg/mL, NT-proBNP concentration <300 pg/mL. One must note, however, that elevated NT-proBNP can also be found in many other cardiac and non-cardiac conditions
  • lung ultrasound is more accurate than auscultation or chest x-ray for the detection of pulmonary congestion in acute dyspnoea, and should be considered where available (Harjola et al., 2017)

The following laboratory tests should be carried out:

  • cardiac troponin
  • blood urea nitrogen (BUN) or urea
  • creatinine
  • sodium
  • potassium
  • thyroid-stimulating hormone (TSH)
  • glucose
  • liver function

An algorithm for the diagnosis of heart failure in the non-acute setting is shown in Figure 8.

Diagnostic algorithm for diagnosis of heart failure of non-acute onset

Figure 8. Diagnostic algorithm for diagnosis of heart failure of non-acute onset (adapted from Ponikowski et al, 2016).
BNP, B-type natriuretic peptide; CAD, coronary artery disease; ECG, electrocardiogram; HF, heart failure; MI, myocardial infarction; NT-proBNP, N-terminal pro-B type natriuretic peptide.

A recent pilot study explored whether a lung and cardiac ultrasound protocol could aid in the diagnosis of acute heart failure. The scans were carried out by an experienced emergency physician, and a positive result was considered to be the identification of B+ lines in both anterosuperior lung zones, plus a left ventricular ejection fraction less than 45%. Tested on 99 patients, the sensitivity was 25% (95% CI 14–41%) and the specificity was 100% (95% CI 94–100%). The protocol took under 2 minutes to perform on average, leading the investigators to conclude that it may represent an important screening tool for rapid assessment (Russell & Ehrman, 2017).