Perspective:

This document describes appropriate use criteria for imaging tests in patients with heart failure, organized into five clinical scenarios:

1. For the initial evaluation of patients with newly suspected or potential heart failure, imaging may be clinically useful to define cardiac anatomy and function. Across a range of categories, only resting echocardiography and cardiac magnetic resonance (CMR) imaging are consistently graded as appropriate; other imaging modalities may be appropriate in selected patients. Stress imaging is considered ‘maybe’ or ‘rarely’ appropriate.

2. In patients with heart failure, imaging may be useful to evaluate for a potential ischemic etiology. In these patients, rest/stress imaging and invasive coronary angiography is appropriate in all individuals; cardiac computed tomography (CCT) is also appropriate in patients with symptoms consistent with ischemia.

3. For patients with heart failure and an ischemic etiology amenable to revascularization, imaging may be helpful to evaluate viability. Across a range of cardiac dysfunction, stress/rest echocardiography, stress/rest single-photon emission computed tomography (SPECT), and stress/rest or rest-only CMR are considered appropriate. Stress/rest or rest-only positron emission tomography (PET) and rest/redistribution SPECT are considered appropriate in selected patients.

4. Imaging may be clinically useful in heart failure patients under consideration for implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT), or for follow-up after these procedures. For initial evaluation of possible ICD or CRT candidacy, resting echocardiography, radionuclide ventriculography, and CMR are appropriate. Echocardiography, CCT, and CMR are appropriate for CRT planning purposes. For clinically warranted follow-up after ICD or CRT, only resting echocardiography is appropriate.

5. Repeat noninvasive imaging may be helpful in patients with known heart failure. In patients with new angina or angina equivalent symptoms, rest or rest/stress echocardiography, rest/stress SPECT, or invasive coronary angiography are appropriate. For patients with new or worsening heart failure symptoms adherent to medical therapy, rest or rest/stress echocardiography and rest/stress SPECT are appropriate. Any imaging tests in the absence of new symptoms or change in clinical status are ‘rarely’ appropriate; the exception is that repeat echocardiography >1 year following prior imaging is ‘maybe’ appropriate.