Be aware that: obesity, African or African-Caribbean family origin, or treatment with diuretics, angiotensin- converting enzyme(ACE) inhibitors , beta-blockers, angiotensin II receptor blockers (ARBs) or mineralcorticoid receptor antagonist (MRAs) can reduce levels of serum natriuretic peptides. high levels of serum natriuretic peptides can have causes other than heart failure (for example, age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [eGFR ], sepsis, chronic obstructive pulmonary disease, diabetes, or cirrhosis of the liver). [2010, amended 2018] 8. Perform transthoracic echocardiography to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts. 9. Transthoracic echocardiography should be performed on high-resolution equipment, by experienced operators trained to the relevant professional standards. Need and demand for these studies should not compromise quality. [2003, amended 2018] 10.Ensure that those reporting echocardiography are experienced in doing so. [2003] Chronic Heart Failure Diagnosing heart failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 11.Consider alternative methods of imaging the heart (for example, radionuclide angiography [multigated acquisition scanning], cardiac MRI or transoesophageal echocardiography) if a poor image is produced by transthoracic echocardiography. [2003, 12.Perform an ECG and consider the following tests to evaluate possible aggravating factors and/or alternative diagnoses: chest X-ray blood tests: renal function profile thyroid function profile liver function profile lipid profile glycosylated haemoglobin (HbA1c) full blood count urinalysis peak flow or spirometry. [2010, amended 2018] 13.Try to exclude other disorders that may present in a similar manner.[2003] 14.When a diagnosis of heart failure has been made, assess severity, aetiology, precipitating factors, type of cardiac dysfunction and correctable causes. [2010] 5.4.2 Heart failure caused by valve disease 15.Refer people with heart failure caused by valve disease for specialist assessment and advice regarding follow-up. 