ACC/ACR release recommendations on imaging in heart failure

Recommendations on the appropriate use of imaging in heart failure patients were released by the American College of Radiology and the American College of Cardiology Foundation last week.

This first joint effort on the subject covered the use of imaging for initial diagnosis and evaluation, decisions about revascularization and device implantation, and long-term follow-up, among other indications. The writing group reviewed available literature, presented common clinical scenarios and came to recommendations on the use of 11 possible tests, including rest and rest/stress tests for echo, radionuclide imaging and cardiac magnetic resonance (CMR) imaging, as well as cardiac CT and invasive cardiac catheterization. Resting electrocardiograms and chest X-rays were not included, since they were considered part of routine care.

For patients being initially evaluated for potential or suspected heart failure, the experts recommended echo and CMR and saw no role for stress cardiovascular testing, cardiac CT or invasive angiography. If the only information needed is ejection fraction, radionuclide ventriculography may also be useful. Once heart failure has been diagnosed, the preferred imaging strategies are stress testing, angiography with CT or invasive cardiac catheterization, the experts said.

To select patients for device therapy, echo and CMR are useful, as is cardiac CT. Most such patients do not need a stress evaluation or invasive cardiac catheterization, according to the recommendations. If patients have a change in clinical status (including device activation), reevaluation of left ventricular function is appropriate, but routine follow-up of ejection fraction is rarely appropriate, with the possible exception of echocardiography. In general, patients with changing or worsening symptoms should be tested similarly to those being initially evaluated. If there are additional concerns of ischemia, stress testing is reasonable. For patients with no change in symptoms, testing is rarely appropriate, the experts concluded.

Heart failure patients vary greatly in presentation, so the recommendations should be used in conjunction with sound clinical judgment, the authors noted. They believe that implementation of the criteria could lead to high-quality and efficient care but also noted that the evidence in this area is rapidly evolving and the document will likely need to be updated. The recommendations were published early online by the Journal of the American College of Cardiology on April 23.