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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e915 CLINICAL STATEMENTS AND GUIDELINES

of interstitial space characteristics and extracellular volume fraction and provides diagnostic and prognostic information.19,21–23,68–71 The presence of delayed hyperenhancement has been associated with worse outcomes and can provide risk stratification.72–77 Although registry data show that CMR findings commonly impact patient care management and provide diagnostic information in patients with suspected myocarditis or cardiomyopathy,17,18 a strategy of routine screening with CMR in patients with nonischemic cardiomyopathy was not shown to yield more specific HF causes than a strategy of selective CMR strategy based on echocardiographic and clinical findings in a recent trial.78 6.	 HF is often caused by coronary atherosclerosis,79 and evaluation for ischemic heart disease can help in determining the presence of significant coronary artery disease (CAD). Noninvasive stress imaging with echocardiography or nuclear scintigraphy can be helpful in identifying patients likely to have obstructive CAD.24,25 Invasive or computed tomography coronary angiography can detect and characterize extent of CAD.26,27 7.	 CAD is a leading cause of HF79 and myocardial ischemia may contribute to new or worsening HF symptoms. Noninvasive testing (ie, stress echocardiography, SPECT, CMR, or PET) may be considered for detection of myocardial ischemia to help guide coronary revascularization decisions. Multiple nonrandomized, observational studies have reported improved survival with revascularization in patients with viable but dysfunctional myocardium.28,30–32 Despite these observational data, RCTs have not shown that viability imaging improves guidance of revascularization to a reduction of adverse cardiovascular outcomes.80–82 A prespecified viability substudy of the STICH (Surgical Treatment for Ischemic Heart Failure) trial showed that the presence of myocardial viability did not determine the longterm benefit from surgical revascularization in patients with ischemic cardiomyopathy.81,82 Of note, a relatively small number of individuals enrolled in the STICH substudy did not have viability, which may limit the power of the study. Although these data do not support the concept of routine viability assessment before revascularization, myocardial viability is used as one of the tools to inform decisions regarding revascularization in patients with high surgical risk or with complex medical problems. 8.	 Repeat noninvasive imaging of cardiac structure and function for routine surveillance is rarely appropriate in the absence of a change in clinical status or treatment interventions.11,83 4.5 Invasive Evaluation

Recommendations for Invasive Evaluation Referenced studies that support the recommendations are summarized in the Online Data Supplements.

COR LOE Recommendations

2a B-NR 1.	 In patients with HF, endomyocardial biopsy may be useful when a specific diagnosis is suspected that would influence therapy.1,2

2a C-EO 2.	 In selected patients with HF with persistent or worsening symptoms, signs, diagnostic parameters, and in whom hemodynamics are uncertain, invasive hemodynamic monitoring can be useful to guide management.

3: No Benefit B-R 3.	 In patients with HF, routine use of invasive hemodynamic monitoring is not recommended.3,4

3: Harm C-LD 4.	 For patients undergoing routine evaluation of HF, endomyocardial biopsy should not be performed because of the risk of complications.5,6

Synopsis Invasive evaluation of patients with HF may provide important clinical information to determine the cause of HF and treatment options. Routine right heart catheterization does not provide sufficient information to guide treatment decisions.3,4 However, hemodynamic evaluation with right heart catheterization and monitoring in the setting of acute respiratory distress, systemic hypoperfusion including cardiogenic shock, or when hemodynamics are uncertain, may guide treatment decisions. Coronary angiography may be useful in patients who are candidates for revascularization7–9 (see Section 4.4, “Evaluation with Cardiac Imaging,” for recommendations). Endomyocardial biopsy may be advantageous in patients with HF in which a histological diagnosis, such as amyloidosis or myocarditis, may influence treatment decisions.1,2

Recommendation-Specific Supportive Text

1.	 Endomyocardial biopsy may be useful when seeking a specific diagnosis that would influence treatment, and biopsy should thus be considered in patients with rapidly progressive clinical HF or worsening ventricular dysfunction that persists despite appropriate medical treatment. Endomyocardial biopsy should also be considered in patients suspected of having acute cardiac rejection status after heart transplantation or having myocardial infiltrative processes. A specific example is to determine treatment for light chain (AL) amyloidosis or transthyretin amyloidosis.5 Additional indications for endomyocardial biopsy include patients with rapidly progressive and unexplained cardiomyopathy and those in whom active myocarditis, especially giant cell myocarditis, is being considered.1

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