Congestive heart failure laboratory tests

Resident Survival Guide

Congestive Heart Failure Microchapters
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Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]; Seyedmahdi Pahlavani, M.D. [3]; Tarek Nafee, M.D. [4]

Overview

Once the diagnosis of heart failure is made, subsequent laboratory studies should be directed toward the identification of an underlying cause of heart failure.

Laboratory Tests

Renal Function

Renal function should be assessed as a rough guide to the patient's intravascular volume status and renal perfusion. A urinalysis is helpful in the assessment of the patient's volume status. Electrolyte assessment and the correction of electrolyte disturbances such as hypokalemia, hyperkalemia and hypomagnesemia is critical in those patients treated with diuretics. Hyponatremia (due to poor stimulation of the baroreceptors and appropriate ADH release and free water retention) is associated with a poor prognosis.

Hematologic Studies

A complete blood count should be obtained to assess for the presence of anemia which may exacerbate heart failure and to assess the patients coagulation status which may be impaired due to hepatic congestion.

Thyroid Studies

The assessment of thyroid function tests is particularly important in the patient who is being treated with concomitant therapy with an agent such as amiodarone.

Biomarkers

Biomarkers are going to play a great role in diagnosis of heart failure.

Natriuretic Peptides: BNP or NT-proBNP

• Plasma concentrations of NPs are recommended as initial diagnostic tests in patients with symptoms suggestive of HF to rule out the diagnosis.
• Elevated concentrations support a diagnosis of HF.
• Other causes of an elevated NP include atrial fibrillation, increasing age, and acute or chronic kidney disease.
• NP concentrations may be low in obese patients.
• The upper limits of normal in the non-acute setting are 35 pg/mL for BNP, and 125 pg/mL for NT-proBNP.

Causes of elevated concentrations of natriuretic peptides

Cardiac:

❑ Heart failure ❑ ACS ❑ Pulmonary embolism ❑ Myocarditis ❑ Left ventricular hypertrophy ❑ Hypertrophic cardiomyopathy, restrictive cardiomyopathy ❑ Valvular heart disease ❑ Congenital heart disease ❑ Atrial tachyarrhythmia , ventricular tachyarrhythmias ❑ Heart contusion ❑ Cardioversion, ICD shock ❑ Surgical procedures involving the heart ❑ Pulmonary hypertension

Non-Cardiac :

❑ Advanced age ❑Ischaemic stroke ❑Subarachnoid haemorrhage ❑Renal dysfunction ❑Liver dysfunction (mainly liver cirrhosis with ascites) ❑Paraneoplastic syndrome ❑COPD ❑Severe infections (including pneumonia and sepsis) ❑Severe burns ❑Anemia ❑Severe metabolic and hormone abnormalities (thyrotoxicosis, diabetic ketosis)

The above table adopted from 2021 ESC Guideline

• BNP or its amino-terminal cleavage equivalent (NT-proBNP) is generated by cardiomyocytes in the context of numerous triggers, most notably myocardial stretch.
• BNP levels may be useful in the initial establishment of the diagnosis of heart failure in the patient with dyspnea of unclear etiology. In a meta-analysis, BNP was superior N-terminal pro-BNP (NTproBNP) and was associated with a sensitivity of 85% and specificity of 84% in the diagnosis of heart failure in the primary care setting.

• These biomarkers have been studied for the detection of elevated cardiac pressures., low ejection fraction, or both.
• Clinical practice guidelines suggest their measurement is helpful for diagnosis or ruling out heart failure especially in the acute settings.

Biomarkers indications for use

Abbreviations: ACC: American College of Cardiology, AHA: American Heart Association, ADHF: acute decompensated heart failure, BNP: B-type natriuretic peptide, COR: Class of Recommendation, ED: emergency department, HF: heart failure, NT-proBNP: N-terminal pro-B-type natriuretic peptide, NYHA: New York Heart Association, pts: patients

(*)Other biomarkers of injury or fibrosis include soluble ST2 receptor, galectin-3, and high-sensitivity troponin.

Biomarkers of Myocardial Injury: Cardiac Troponin T or I

Even without obvious myocardial ischemic injury, troponin level may be increased in heart failure which means undergoing myocyte injury. Elevated levels of troponin is associated with impaired hemodynamics, progressive LV dysfunction and increased mortality rates.

Carbohydrate Antigen 125

CA-125 is an emerging, highly sensitive biomarker for heart failure. Although it is not yet used in clinical practice, the CHANCE-HF trial has demonstrated utility in using CA-125 to guide diuretic therapy and for determining short-term prognosis. CA-125 is a non-specific antigen that is most strongly associated with ovarian cancer. In patients with acute heart failure, ambulatory follow-up care aimed at titrating diuretic use according to CA-125 levels has demonstrated ~50% reduction in rehospitalizations. CA-125 was first associated with heart failure in 1999 by Nagele et al.

Initial lab tests for evaluation of HFrEF

• BNP, NT Pro BNP
• CBC, basic metabolic panel, liver function, Iron studies, thyroid studies, Hb A1C