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Exercise or pharmacological stress echocardiography may be used for the assessment of inducible ischaemia in those who are considered suitable for coronary revascularization.81 In patients with HFpEF, valve disease, or unexplained dyspnoea, stress echocardiography might help clarify the diagnosis.82 Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE), T1 mapping and extracellular volume will identify myocardial fibrosis/scar, which are typically subendocardial for patients with ischaemic heart disease (IHD) in contrast to the mid-wall scar typical of dilated cardiomyopathy (DCM). In addition, CMR allows myocardial characterization in, e.g. myocarditis, amyloidosis, sarcoidosis, Chagas disease, Fabry disease, LV non-compaction CMP, haemochromatosis, and arrhythmogenic cardiomyopathy (AC).83,84 Computed tomography coronary angiography (CTCA) may be considered in patients with a low to intermediate pre-test probability of CAD, or those with equivocal non-invasive stress tests in order to exclude the diagnosis of CAD.5 Single-photon emission CT (SPECT) can also be used to assess myocardial ischaemia and viability, myocardial inflammation or infiltration. Scintigraphy with technetium (Tc)-labelled bisphosphonate has shown high sensitivity and specificity for imaging cardiac transthyretin amyloid.85 ESC 2021 Recommendations for specialized diagnostic tests for selected patients with chronic heart failure to detect reversible/treatable causes of heart failure

Recommendations Classa Levelb

CMR CMR is recommended for the assessment of myocardial structure and function in those with poor echocardiogram acoustic windows. I C CMR is recommended for the characterization of myocardial tissue in suspected infiltrative disease, Fabry disease, inflammatory disease (myocarditis), LV non-compaction, amyloid, sarcoidosis, iron overload/haemochromatosis. I C CMR with LGE should be considered in DCM to distinguish between ischaemic and non-ischaemic myocardial damage. IIa C Invasive coronary angiography (in those who are considered eligible for potential coronary revascularization) Invasive coronary angiography is recommended in patients with angina despite pharmacological therapy or symptomatic ventricular arrhythmias.5 I B Invasive coronary angiography may be considered in patients with HFrEF with an intermediate to high pre-test probability of CAD and the presence of ischaemia in non-invasive stress tests.89 IIb B Non-invasive testing CTCA should be considered in patients with a low to intermediate pre-test probability of CAD or those with equivocal non-invasive stress tests in order to rule out coronary artery stenosis. IIa C Non-invasive stress imaging (CMR, stress echocardiography, SPECT, PET) may be considered for the assessment of myocardial ischaemia and viability in patients with CAD who are considered suitable for coronary revascularization.9093 IIb B Exercise testing may be considered to detect reversible myocardial ischaemia and investigate the cause of dyspnoea.9496 IIb C Cardiopulmonary exercise testing Cardiopulmonary exercise testing is recommended as a part of the evaluation for heart transplantation and/or MCS.9496 I C Cardiopulmonary exercise testing should be considered to optimize prescription of exercise training.9496 IIa C Cardiopulmonary exercise testing should be considered to identify the cause of unexplained dyspnoea and/or exercise intolerance.9496 IIa C Right heart catheterization Right heart catheterization is recommended in patients with severe HF being evaluated for heart transplantation or MCS. I C

Continued

Table 7 Causes of elevated concentrations of natriuretic peptides86-88

Cardiac Heart failure ACS

Pulmonary embolism Myocarditis Left ventricular hypertrophy Hypertrophic or restrictive cardiomyopathy Valvular heart disease Congenital heart disease Atrial and 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 Anaemia Severe metabolic and hormone abnormalities

(e.g. thyrotoxicosis, diabetic ketosis)

ACS = acute coronary syndrome; COPD = chronic obstructive pulmonary disease; ICD = implantable cardioverter-defibrillator. ............................................................................................................................................................................ Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026