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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e910

CLINICAL STATEMENTS AND GUIDELINES 4.1.1 Initial Laboratory and Electrocardiographic Testing

Recommendations for Initial Laboratory and Electrocardiographic Testing Referenced studies that support the recommendations are summarized in the Online Data Supplements.

COR LOE Recommendations

1 B-NR 1.	 For patients presenting with HF, the specific cause of HF should be explored using additional laboratory testing for appropriate management.1–8

1 C-EO 2.	 For patients who are diagnosed with HF, laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management.

1 C-EO 3.	 For all patients presenting with HF, a 12-lead ECG should be performed at the initial encounter to optimize management.

Synopsis Laboratory evaluation with complete blood count, urinalysis, serum electrolytes (including sodium, potassium, calcium, and magnesium), blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, iron studies (serum iron, ferritin, transferrin saturation), and thyroid-stimulating hormone level and electrocardiography is part of the standard diagnostic evaluation of a patient with HF. In addition to routine assessment, specific diagnostic testing and evaluation is often necessary to identify specific cause and other comorbidities in patients with HF.

Recommendation-Specific Supportive Text

1.	 Identifying the specific cause of HF is important, because conditions that cause HF may require disease-specific therapies. Depending on the clinical suspicion, additional diagnostic studies are usually required to diagnose specific causes (Table 6) such as ischemic cardiomyopathy, cardiac amyloidosis, sarcoidosis, hemochromatosis, infectious mechanisms (eg, HIV, COVID-19, Chagas), hypothyroidism, hyperthyroidism, acromegaly, connective tissue disorders, tachycardia-induced cardiomyopathy, Takotsubo, peripartum cardiomyopathy, cardiotoxicity with cancer therapies, or substance abuse would require specific management in addition to or beyond GDMT.1,2,9–15 2.	 Laboratory evaluation with complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, iron studies (serum iron, ferritin, transferrin saturation), and thyroid-stimulating hormone levels provides important information regarding patients’ comorbidities, suitability for and adverse effects of treatments, potential causes or confounders of HF, severity and prognosis of HF, and is usually performed on initial evaluation. Pertinent laboratory tests are repeated with changes in clinical condition or treatments (eg, to monitor renal function or electrolytes with diuretics). 3.	 Electrocardiography is part of the routine evaluation of a patient with HF and provides important information on rhythm, heart rate, QRS morphology and duration, cause, and prognosis of HF. It is repeated when there is a clinical indication, such as a suspicion for arrhythmia, ischemia or myocardial injury, conduction, or other cardiac abnormalities.

Table 6.  Selected Potential Causes of Elevated Natriuretic Peptide Levels50–53 Cardiac HF, including RV HF syndromes ACS Heart muscle disease, including LVH VHD Pericardial disease AF Myocarditis Cardiac surgery Cardioversion Toxic-metabolic myocardial insults, including cancer chemotherapy Noncardiac Advancing age Anemia Renal failure Pulmonary: Obstructive sleep apnea, severe pneumonia Pulmonary embolism, pulmonary arterial hypertension Critical illness Bacterial sepsis Severe burns ACS indicates acute coronary syndromes; AF, atrial fibrillation; HF, heart failure; LVH, left ventricular hypertrophy; RV, right ventricular; and VHD, valvular heart disease.

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