New-onset heart failure
Recommended: Transthoracic Echocardiogram is the preferred imaging study for new-onset heart failure. Differentiates HFrEF / HFpEF.
Recommended study
Transthoracic Echocardiogram
Differentiates HFrEF / HFpEF. Cardiac MRI for cause when echo non-diagnostic.
If the default doesn't apply
Etiology unclear after echo (infiltrative, ischemic, inflammatory)
MRI
Cardiac MRI with LGE
IV contrast
Ischemic etiology suspected
CT
Coronary CTA or invasive coronary angiography
IV contrast
Watch-outs
Acute decompensation with hypoxemia
CXR + bedside echo first; identify reversible causes (volume overload, valvular catastrophe).
Right heart failure
Consider chronic PE / CTEPH, cor pulmonale, ARVC — image accordingly.
Pearls
- BNP / NT-proBNP supports diagnosis but is affected by renal function, age, obesity, AF.
- TTE: LVEF + diastolic function + chamber sizes + valves + pericardium in single study.
- Cardiac MRI with LGE distinguishes ischemic (subendocardial) from non-ischemic (mid-wall / epicardial) patterns.