The European Society of Cardiology (ESC) in May released a new guideline for the diagnosis and management of heart failure (HF), the first significant update to its 2012 recommendations.

Among the changes are clearer recommendations for diagnosing various types of HF, and a new algorithm for the diagnosis of HF in non-acute settings based on assessment of HF probability. The guidelines also introduce a new term for patients with HF and a left ventricular ejection fraction (LVEF) between 40% and 49%: HF with midrange EF (HFmrEF).

“Identifying HFmrEF as a separate group will stimulate research into the underlying characteristics, pathophysiology, and treatment of this population,” committee members wrote.

In addition to clinical history and physical examination findings, the new algorithm considers natriuretic peptide (NP) levels. The committee defines “elevated” as N-terminal pro-B type NP (NT-proBNP) ≥125 pg/mL and/or BNP ≥35 pg/mL.

Other recommended diagnostic tests in the non-acute care setting include:

  • Hemoglobin and white blood cell count
  • Sodium, potassium, urea, creatinine (with estimated glomerular filtration rate)
  • Liver function tests (bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transpeptidase)
  • Glucose, HbA1c
  • Thyroid stimulating hormone (TSH)
  • Ferritin, transferrin saturation = total iron-binding capacity

The ESC committee noted that while there is “extensive research” on biomarkers in HF, such as ST2, galectin 3, copeptin, and adrenomedullin, there is no “definite evidence” to recommend them for clinical practice.

Genetic Testing in Heart Failure

The committee recommends molecular genetic analysis in patients with HF only if there is a high prevalence of detectable mutations, not to confirm the diagnosis. Specifically, the authors recommend genetic counseling for patients with hypertrophic cardiomyopathy, idiopathic dilated cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy.

Laboratory Tests in the Acute-Care Setting

The committee did not make any substantive changes to the 2012 recommendations for laboratory testing in the acute-care setting. They call for all patients with acute dyspnea and suspected acute HF at presentation to have a plasma natriuretic peptide level (BNP, NT-proBNP or mid-regional pro A-type NP) to rule out non-cardiac causes of acute dyspnea.

Once admitted, patients should have measurements taken of cardiac troponin, blood urea nitrogen (or urea), creatinine, electrolytes (sodium, potassium), glucose, complete blood count, liver function, and TSH.