Heart failure and cardiac imaging: Choosing wisely in the era of multimodality imaging

Heart failure is the common final outcome of many heart diseases. Cardiac imaging plays a central role in its diagnosis and etiological work-up. Given the large array of imaging modalities, as well as structural and functional parameters, devising a diagnostic strategy that provides diagnostic accuracy without wasting resources can be challenging. “Multimodality imaging” has become a popular buzzword without a clear meaning, except for different modalities showing different aspects, which sometimes may be helpful and sometimes not. Is multimodality imaging per se diagnostically superior? When should we escalate from echocardiography to other modalities? In this viewpoint article, we attempt to provide guidelines on the rational deployment of modern imaging armamentarium in heart failure.The role of echocardiography in the diagnosis of heart failure In patients with symptoms suggestive of heart failure, after the history taking, physical examination, electrocardiogram evaluation, and perhaps drawing blood for natriuretic peptides, the next diagnostic step is unquestionably an echocardiogram (1, 2). This can usually – unless in special circumstances, such as forbidding acoustical windows – address the following fundamental questions: - What are the left ventricular size, ejection fraction, and global longitudinal strain? - Are there signs of diastolic left ventricular dysfunction? - Are there regional wall motion abnormalities suggesting coronary artery disease (CAD)? - Is there left ventricular remodeling or hypertrophy? - Is there (major) valvular heart disease? Are there structural abnormalities suggesting cardiomyopathy? - Are there right ventricular abnormalities, congenital heart disease (e.g., atrial septal defect), or other major structural abnormalities?