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......................................... The diagnostic workup of AHF starts at the time of the first medical contact, and is continued throughout the initial patient pathway, aiming to identify the clinical presentation and to diagnose and manage any potentially reversible causes/precipitants/coexisting life-threatening conditions in a timely manner (Figure 6). Diagnostic tests are outlined at Table 20. In addition to clinical signs and symptoms, diagnostic workup includes ECG and echocardiography, if possible. Additional investigations, i.e. chest X-ray and lung ultrasound may be used to confirm AHF diagnosis, especially when NP testing is not available. Plasma NP levels (BNP or NT-proBNP or MRproANP) should be measured if the diagnosis is uncertain and a point-of-care assay is available. Normal concentrations of NPs make the diagnosis of AHF unlikely. Cut-offs for acute HF are: BNP <100 pg/mL, NT-proBNP <300 pg/mL and MR-proANP <120 pg/ mL.74,433435 However, elevated NP values are associated with a wide range of cardiac and non-cardiac conditions (Table 6). Low concentrations can be detected in some patients with advanced decompensated end-stage HF, obesity, flash pulmonary oedema or rightsided AHF. Higher levels can be found in the patients with concomitant AF and/or reduced renal function.74

Among other laboratory tests, troponin is useful for the detection of acute coronary syndrome (ACS) although elevated levels are detected in the vast majority of patients with AHF.436438 Blood urea nitrogen or urea, serum creatinine, electrolytes (sodium, potassium, chloride), and antigen carbohydrate 125 may help tailor treatment.439,440 Detection of abnormal liver function identifies patients

Diagnostic workup of new onset acute heart failure

Electrocardiogram Pulse oximetry Echocardiography Initial laboratory investigationsa Chest X-ray Lung ultrasound Other specific evaluationsb

Patient history, signs and/or symptoms suspected of acute HF

Natriuretic peptide testing

BNP <100 pg/mL NT-proBNP <300 pg/mL MR-proANP <120 pg/mL BNP ≥ 100 pg/mL NT-proBNP ≥300 pg/mLc

MR-proANP ≥120 pg/mL

Acute heart failure ruled out Acute heart failure confirmed

Comprehensive echocardiography

Figure 6 Diagnostic workup of new onset acute heart failure. ACS = acute coronary syndrome; BNP= B-type natriuretic peptide; CT= computed tomography; HF= heart failure; MR-proANP= mid-regional pro-atrial natriuretic peptide; NT-proBNP= N-terminal pro-B-type natriuretic peptide; TSH = thyroid-stimulating hormone. aInitial laboratory exams include troponin, serum creatinine, electrolytes, blood urea nitrogen or urea, TSH, liver function tests as well as D-dimer and procalcitonin when pulmonary embolism or infection are suspected, arterial blood gas analysis in case of respiratory distress, and lactate in case of hypoperfusion. bSpecific evaluation includes coronary angiography, in case of suspected ACS, and CT in case of suspected pulmonary embolism. cRule-in values for the diagnosis of acute HF: >450 pg/mL if aged <55 years, >900 pg/mL if aged between 55 and 75 years and >1800 pg/mL if aged >75 years.433,434 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026