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Table 5 Causes of heart failure, common modes of presentation and specific investigations

Cause Examples of presentations Specific investigations CAD Myocardial infarction Angina or “angina-equivalent”

Arrhythmias Invasive coronary angiography CT coronary angiography

Imaging stress tests (echo, nuclear, CMR)

Hypertension Heart failure with preserved systolic function Malignant hypertension/acute pulmonary oedema 24 h ambulatory BP Plasma metanephrines, renal artery imaging

Renin and aldosterone

Valve disease Primary valve disease e.g., aortic stenosis

Secondary valve disease, e.g. functional regurgitation Congenital valve disease Echo  transoesophageal/stress

Arrhythmias Atrial tachyarrhythmias

Ventricular arrhythmias Ambulatory ECG recording

Electrophysiology study, if indicated

CMPs All Dilated

Hypertrophic Restrictive ARVC Peripartum Takotsubo syndrome Toxins: alcohol, cocaine, iron, copper CMR, genetic testing

Right and left heart catheterization

CMR, angiography Trace elements, toxicology, LFTs, GGT

Congenital heart disease Congenitally corrected/repaired transposition of great arteries

Shunt lesions Repaired tetralogy of Fallot Ebstein’s anomaly CMR

Infective Viral myocarditis

Chagas disease HIV Lyme disease CMR, EMB

Serology

Drug-induced Anthracyclines Trastuzumab

VEGF inhibitors Immune checkpoint inhibitors Proteasome inhibitors RAFþMEK inhibitors

Infiltrative Amyloid

Sarcoidosis Neoplastic Serum electrophoresis and serum free light chains, Bence

Jones protein, bone scintigraphy, CMR, CT-PET, EMB Serum ACE, CMR, FDG-PET, chest CT, EMB CMR, EMB

Storage disorders Haemochromatosis Fabry disease

Glycogen storage diseases Iron studies, genetics, CMR (T2* imaging), EMB a-galactosidase A, genetics, CMR (T1 mapping)

Endomyocardial disease Radiotherapy

Endomyocardial fibrosis/eosinophilia Carcinoid CMR

EMB 24 h urine 5-HIAA

Pericardial disease Calcification

Infiltrative Chest CT, CMR, right and left heart catheterisation

Metabolic Endocrine disease Nutritional disease (thiamine, vitamin B1 and selenium deficiencies)

Autoimmune disease TFTs, plasma metanephrines, renin and aldosterone, cortisol Specific plasma nutrients

ANA, ANCA, rheumatology review

Neuromuscular disease Friedreich’s ataxia Muscular dystrophy Nerve conduction studies, electromyogram, genetics CK, electromyogram, genetics 5-HIAA = 5-hydroxyindoleacetic acid; ACE = angiotensin-converting enzyme; ANA = anti-nuclear antibody; ANCA = anti-nuclear cytoplasmic antibody; ARVC = arrhythmogenic right ventricular cardiomyopathy; BP = blood pressure; CAD = coronary artery disease; CMP = cardiomyopathy; CMR = cardiac magnetic resonance; CK = creatinine kinase; CT = computed tomography; ECG = electrocardiogram; Echo = echocardiography; EMB = endomyocardial biopsy; FDG = fluorodeoxyglucose; GGT = gamma-glutamyl transferase; HIV = human immunodeficiency virus; h = hour; LFT = liver function test; LGE = late gadolinium enhancement; MEK = mitogen-activated protein kinase; PET = positron emission tomography; TFT = thyroid function test; VEGF = vascular endothelial growth factor. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026