A 58-year-old man with a 3-year history of hypertension presents with progressive dyspnea on exertion, orthopnea, and peripheral edema for 2 weeks. Physical examination reveals elevated JVP, bilateral crackles, and a displaced apex beat. BNP is elevated at 450 pg/mL. Which investigation is most appropriate to determine the underlying etiology and guide management?

## Investigation of Choice in Heart Failure Diagnosis **Key Point:** Transthoracic echocardiography is the first-line and most appropriate investigation for evaluating suspected heart failure. It provides essential structural and functional information required for diagnosis and classification. ## Why Echocardiography is the Answer ### Diagnostic Value Echocardiography determines: - Left ventricular ejection fraction (LVEF) — essential for HF classification (HFrEF vs HFmrEF vs HFpEF) - Chamber dimensions and wall thickness - Diastolic function parameters - Valvular abnormalities - Regional wall motion abnormalities suggesting prior MI - Estimated pulmonary artery pressure ### Clinical Role in This Case This patient has clinical signs of heart failure (dyspnea, orthopnea, edema, elevated JVP, crackles, displaced apex) with elevated BNP. Echocardiography will: 1. Confirm the diagnosis by documenting systolic or diastolic dysfunction 2. Classify the type of HF (systolic vs diastolic) 3. Guide initial pharmacotherapy (ACE inhibitors, beta-blockers, MRAs for HFrEF) 4. Identify reversible causes (valvular disease, pericardial effusion) **High-Yield:** Echocardiography is recommended in all patients with suspected HF by current guidelines (ESC, ACC/AHA) as the initial imaging modality. ## When Other Investigations Are Indicated | Investigation | Indication | Timing | |---|---|---| | Coronary angiography | HFrEF + angina or ischemic features on ECG/stress test | After stabilization; not routine | | Cardiac MRI | Suspected infiltrative/inflammatory disease; complex cardiomyopathy | Specialist referral | | Endomyocardial biopsy | Suspected myocarditis, amyloidosis, or HF of unclear etiology | Rarely; high risk | **Clinical Pearl:** In this hypertensive patient with HF, echocardiography may show concentric LV hypertrophy with preserved EF (HFpEF), which is common in hypertension-related HF. **Mnemonic — HF Workup Order (ECHO-CATH):** - **E**chocardiography — first-line - **C**oronary angiography — if ischemia suspected - **H**olter/stress — if arrhythmia or ischemia - **O**ther imaging (MRI, PET) — specialist indication - **C**atheterization (right heart) — if hemodynamics unclear - **A**dvanced testing (biopsy) — rare, specific indication - **T**issue Doppler — part of echo - **H**istology — only if biopsy done