Heart involvement, including primary myocardial involvement, is very common in systemic sclerosis (SSc). When clinically evident, cardiac involvement is recognized to be a very poor prognostic factor. Thus pre-clinical identification is highly encouraged. Echocardiography, including pulsed tissue Doppler echocardiography, is the cornerstone of routine heart assessment as it allows the detection of reduced systolic/ diastolic function, as well as the measurement of pulmonary artery pressure, and the possible detection of valvular or pericardial involvement. Myocardial perfusion may be also assessed by single photon emission computed tomography, and if available, by cardiac magnetic resonance imaging. Since the introduction of routine assay for natriuretic peptides, and their initial application for the diagnosis of acute heart failure, B-type natriuretic peptide assays are now recommended for a wide number of applications and have been introduced as a major tool, in particular in primary care, in worldwide guidelines. Within the context of SSc, recent studies have demonstrated that BNP and NT-proBNP are highly relevant for the diagnosis and the prediction of pulmonary hypertension occurrence. Moreover, NT-proBNP allows the detection of both reduced left ventricular/right ventricular contractility, or pulmonary hypertension, suggesting its potential role as a first line tool in primary care setting for the overall cardiac assessment of SSc in which cardiovascular complications are a burden.