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. 2022 Aug 17;50(1):130–159. doi: 10.1007/s00259-022-05914-6

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© The Author(s) 2024

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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Fig. 3 — Proposed diagnostic algorithm for women with suspected heart failure. In both acute and chronic HF, TTE is the frontline test for the evaluation of cardiac contractility and chamber volumes, in addition to cardiac biomarkers (troponin and brain natriuretic peptide) [114]. Because of TTE’s potential limitations in women, CMR is a useful alternative [127] to assess systolic and diastolic function and determine the type of HF. In chronic HF, ERNA is another option [132, 136], although no longer mentioned in the latest European Society of Cardiology guidelines [114]. In case of HFrEF, the lower rate of ischemic origin in women stresses the importance of CMR with LGE to evaluate alternative etiologies, such as DCM, HCM, VHD [142], ARVC [144], myocarditis, sarcoidosis, and infiltrative diseases. CCTA is also well suited to rule out CAD in women with HFrEF given its high specificity [47]. In selected cardiomyopathies, nuclear imaging is useful for the etiological workup, such as bone scintigraphy and ¹²³I-MIBG SPECT for cardiac amyloidosis [140], ¹⁸F-FDG PET in inflammatory diseases, and nuclear MPI, ¹²³I-MIBG SPECT, and ¹⁸F-FDG PET in TTC [147]. In women with dyspnea and preserved systolic LVEF, an in-depth screening for HFpEF must be considered, based on the four-step algorithm previously mentioned and established by the ESC [120, 130]. Abbreviations: ¹⁸F-FDG: Fluor-18-fluorodeoxyglucose; ¹²³I-MIBG: iodine-123-meta-iodobenzylguanidine; ARVC: arrhythmogenic right ventricular cardiomyopathy; CAD: coronary artery disease; CCTA: coronary computed tomography angiography; CAD CMR: cardiac magnetic resonance; CTRCD: cancer therapy-related cardiac dysfunction; DCM: dilated cardiomyopathy; ERNA: equilibrium radionuclide angiocardiography; HCM: hypertrophic cardiomyopathy; HF: heart failure; HFpEF: heart failure with preserved ejection fraction; HFrEF: heart failure with reduced ejection fraction; ICA: invasive coronary angiography; LA: left atrium; LGE: late gadolinium enhancement; LV: left ventricular; LVEDP: left ventricular end-diastolic pressure; LVEF: left ventricular ejection fraction; mPCWP: mean pulmonary capillary wedge pressure; MPI: myocardial perfusion imaging; PET: positron emission tomography; PPCM: peripartum cardiomyopathy; SPECT: single-photon emission computed tomography; TTC: Takotsubo cardiomyopathy; TTE: transthoracic echocardiography; VHD: valvular heart disease