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....................................... with a poor prognosis.441 Since both hypothyroidism and hyperthyroidism may precipitate AHF, thyroid-stimulating hormone (TSH) should be assessed in those with newly diagnosed AHF. Arterial blood gas analysis should be performed when a precise measurement of O2 and CO2 partial pressure is needed (i.e. patients with respiratory distress). Lactate and pH levels should be measured in patients with cardiogenic shock. D-dimer should be measured when acute pulmonary embolism is suspected. Procalcitonin may be used for the diagnosis of pneumonia and antibiotic therapy may have an indication when plasma levels are >0.2 lg/L. However, no impact of a strategy based on routine procalcitonin measurements on outcomes was shown in a prospective, controlled, trial.442 Pulse oximetry should be measured routinely at the time of first presentation of patients with AHF and continuous monitoring may be needed in the first hours or days.443,444

11.2 Clinical presentations

Four major clinical presentations can be described with possible overlaps between them (Table 21).1,425,445 Clinical presentations are mainly based on the presence of signs of congestion and/or peripheral hypoperfusion and require different treatments (Table 21).1,425427,432,446,447

11.2.1 Acute decompensated heart failure Acute decompensated heart failure (ADHF) is the most common form of AHF, accounting for 5070% of presentations.426,427,432 It

Table 20 Diagnostic tests in patients with acute heart failure

Exam Time of measurement Possible findings Diagnostic value for AHF Indication ECG Admission, during hospitali-

zation,a,b pre-discharge Arrhythmias, myocardial

ischaemia Exclusion of ACS or

arrhythmias Recommended

Chest-X ray Admission, during

hospitalizationa Congestion, lung infection Confirmatory May be considered

LUS Admission, during hospitali-

zation,a pre-discharge Congestion Confirmatory May be considered

Echocardiography Admission, during hospitali-

zation,a pre-discharge Congestion, cardiac dys-

function, mechanical causes Major Recommended

Natriuretic peptides (BNP, NT-proBNP, MR-proANP) Admission, pre-discharge Congestion High negative predictive

value Should be considered

Serum troponin Admission Myocardial injury Exclusion of ACS Recommended Serum creatinine Admission, during hospitali-

zation,a pre-discharge Renal dysfunction None Recommended for prognos-

tic assessment

Serum electrolytes (sodium, potassium, chloride) Admission, during hospitali-

zation,a pre-discharge Electrolyte disorders None Recommended for prognos-

tic assessment and treatment

Iron status (transferrin, ferritin) Pre-discharge Iron depletion None Recommended for prognostic assessment and

treatment

TSH Admission Hypo- hyperthyroidism None Recommended when hypohyperthyroidism is

suspected

D-dimer Admission Pulmonary embolism Useful to exclude pulmo-

nary embolism Recommended when pul-

monary embolism is suspected

Procalcitonin Admission Pneumonia Useful for diagnosis of

pneumonia May be done when pneu-

monia is suspected

Lactate Admission, during hospitalizationa Lactic acidosis Useful to assess perfusion status Recommended when peripheral hypoperfusion is

suspected

Pulse oximetry and arterial blood gas analysis Admission, during hospitalizationa Respiratory failure Useful to assess respiratory function Recommended when respiratory failure is suspected ACS = acute coronary syndrome; AHF = acute heart failure; BNP = B-type natriuretic peptide; ECG = electrocardiogram; LUS = lung ultrasound; MR-proANP = mid-regional pro-atrial natriuretic peptide; NT-proBNP = N-terminal pro-B-type natriuretic peptide; TSH = thyroid-stimulating hormone. aBased on clinical conditions. bContinuous ECG monitoring can be considered based on clinical conditions. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026