Congestive heart failure differential diagnosis: Difference between revisions

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===Other Causes of Dyspnea===
===Other Causes of Dyspnea===
There are non-cardiac causes of [[edema]] that primarily involve the lung or respiratory system.  These conditions are distinguished from heart failure in so far as they do not cause [[peripheral edema]], and they are not be associated with an elevation in [[BNP]].
There are non-cardiac causes of [[edema]] that primarily involve the lung or respiratory system.  These conditions are distinguished from heart failure in so far as they do not cause [[peripheral edema]], and they are not be associated with an elevation in [[BNP]]. CHF should be differentiated from other diseases presenting with [[shortness of breath]] and [[tachypnea]]. The differentials include the following:<ref name="pmid24550636">{{cite journal |vauthors=Brenes-Salazar JA |title=Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era |journal=J Emerg Trauma Shock |volume=7 |issue=1 |pages=57–8 |year=2014 |pmid=24550636 |pmc=3912657 |doi=10.4103/0974-2700.125645 |url=}}</ref><ref name="urlCT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics">{{cite web |url=http://pubs.rsna.org/doi/full/10.1148/rg.245045008 |title=CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis &#124; RadioGraphics |format= |work= |accessdate=}}</ref><ref name="pmid23940438">{{cite journal |vauthors=Bĕlohlávek J, Dytrych V, Linhart A |title=Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism |journal=Exp Clin Cardiol |volume=18 |issue=2 |pages=129–38 |year=2013 |pmid=23940438 |pmc=3718593 |doi= |url=}}</ref><ref name="urlPulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022657/ |title=Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health |format= |work= |accessdate=}}</ref><ref name="pmid20118395">{{cite journal |vauthors=Ramani GV, Uber PA, Mehra MR |title=Chronic heart failure: contemporary diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=2 |pages=180–95 |year=2010 |pmid=20118395 |pmc=2813829 |doi=10.4065/mcp.2009.0494 |url=}}</ref><ref name="pmid18215495">{{cite journal |vauthors=Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL |title=Symptom distress and quality of life in patients with advanced congestive heart failure |journal=J Pain Symptom Manage |volume=35 |issue=6 |pages=594–603 |year=2008 |pmid=18215495 |pmc=2662445 |doi=10.1016/j.jpainsymman.2007.06.007 |url=}}</ref><ref name="pmid19168510">{{cite journal |vauthors=Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ |title=Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology |journal=Eur. J. Heart Fail. |volume=11 |issue=2 |pages=130–9 |year=2009 |pmid=19168510 |pmc=2639415 |doi=10.1093/eurjhf/hfn013 |url=}}</ref><ref name="pmid9465867">{{cite journal |vauthors=Takasugi JE, Godwin JD |title=Radiology of chronic obstructive pulmonary disease |journal=Radiol. Clin. North Am. |volume=36 |issue=1 |pages=29–55 |year=1998 |pmid=9465867 |doi= |url=}}</ref><ref name="pmid14651761">{{cite journal |vauthors=Wedzicha JA, Donaldson GC |title=Exacerbations of chronic obstructive pulmonary disease |journal=Respir Care |volume=48 |issue=12 |pages=1204–13; discussion 1213–5 |year=2003 |pmid=14651761 |doi= |url=}}</ref><ref name="pmid23833163">{{cite journal |vauthors=Nakawah MO, Hawkins C, Barbandi F |title=Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome |journal=J Am Board Fam Med |volume=26 |issue=4 |pages=470–7 |year=2013 |pmid=23833163 |doi=10.3122/jabfm.2013.04.120256 |url=}}</ref><ref name="pmid20511488">{{cite journal |vauthors=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK |title=Pericardial disease: diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=6 |pages=572–93 |year=2010 |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref><ref name="pmid23610095">{{cite journal |vauthors=Bogaert J, Francone M |title=Pericardial disease: value of CT and MR imaging |journal=Radiology |volume=267 |issue=2 |pages=340–56 |year=2013 |pmid=23610095 |doi=10.1148/radiol.13121059 |url=}}</ref><ref name="pmid11680112">{{cite journal |vauthors=Gharib AM, Stern EJ |title=Radiology of pneumonia |journal=Med. Clin. North Am. |volume=85 |issue=6 |pages=1461–91, x |year=2001 |pmid=11680112 |doi= |url=}}</ref><ref name="pmid23507061">{{cite journal |vauthors=Schmidt WA |title=Imaging in vasculitis |journal=Best Pract Res Clin Rheumatol |volume=27 |issue=1 |pages=107–18 |year=2013 |pmid=23507061 |doi=10.1016/j.berh.2013.01.001 |url=}}</ref><ref name="pmid16891436">{{cite journal |vauthors=Suresh E |title=Diagnostic approach to patients with suspected vasculitis |journal=Postgrad Med J |volume=82 |issue=970 |pages=483–8 |year=2006 |pmid=16891436 |pmc=2585712 |doi=10.1136/pgmj.2005.042648 |url=}}</ref><ref name="pmid123074">{{cite journal |vauthors=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW |title=The electrocardiogram in acute pulmonary embolism |journal=Prog Cardiovasc Dis |volume=17 |issue=4 |pages=247–57 |year=1975 |pmid=123074 |doi= |url=}}</ref><ref name="pmid23413894">{{cite journal |vauthors=Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML |title=Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease |journal=COPD |volume=10 |issue=1 |pages=62–71 |year=2013 |pmid=23413894 |doi=10.3109/15412555.2012.727918 |url=}}</ref><ref name="pmid23000104">{{cite journal |vauthors=Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H |title=Electrocardiogram in pneumonia |journal=Am. J. Cardiol. |volume=110 |issue=12 |pages=1836–40 |year=2012 |pmid=23000104 |doi=10.1016/j.amjcard.2012.08.019 |url=}}</ref><ref name="pmid26209947">{{cite journal |vauthors=Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S |title=Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis |journal=Int. J. Cardiol. |volume=199 |issue= |pages=170–9 |year=2015 |pmid=26209947 |doi=10.1016/j.ijcard.2015.06.087 |url=}}</ref><ref name="pmid20112390">{{cite journal |vauthors=Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S |title=Cardiac involvement in Churg-Strauss syndrome |journal=Arthritis Rheum. |volume=62 |issue=2 |pages=627–34 |year=2010 |pmid=20112390 |doi=10.1002/art.27263 |url=}}</ref>
 
<small>
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! colspan="3" |<small>Diagnostic tests</small>
! colspan="3" |<small>Physical Examination</small>
| colspan="7" |<small>Symptoms
! colspan="1" rowspan="2" |<small>Past medical history</small>
! rowspan="2" |<small>Other Findings</small>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<small>CT scan and MRI</small>
!<small>EKG</small>
!<small>Chest X-ray</small> 
!<small>Tachypnea</small>
!<small>Tachycardia</small>
!<small>Fever</small>
!<small>Chest Pain</small>
!<small>Hemoptysis</small>
!<small>Dyspnea on Exertion</small>
!<small>Wheezing</small>
!<small>Chest Tenderness</small>
!<small>Nasalopharyngeal Ulceration</small>
!<small>Carotid Bruit</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pulmonary embolism]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |
* On [[CT angiography]]:
** Intra-luminal filling defect
*On [[MRI]]:
** Narrowing of involved [[Blood vessel|vessel]]
** No contrast seen distal to [[obstruction]]
** Polo-mint sign (partial filling defect surrounded by contrast)
| style="background: #F5F5F5; padding: 5px;" |
* [[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
| style="background: #F5F5F5; padding: 5px;" |
* [[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔ (Low grade)
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔ (In case of massive PE)
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Hypercoagulating conditions ([[Factor V Leiden]], [[thrombophilia]], [[deep vein thrombosis]], immobilization, [[malignancy]], [[pregnancy]])
| style="background: #F5F5F5; padding: 5px;" |
* May be associated with [[metabolic alkalosis]] and [[syncope]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Congestive heart failure]]
| style="background: #F5F5F5; padding: 5px;" |
*On [[Computed tomography|CT scan]]:
** [[Mediastinal lymphadenopathy]]
** Hazy [[mediastinal]] fat
*On [[Magnetic resonance imaging|MRI]]:
** Abnormality of [[cardiac]] chambers ([[Hypertrophy (medical)|hypertrophy]], dilation)
** Delayed enhancement [[MRI]] may help characterize the [[myocardial]] [[Tissue (biology)|tissue]] ([[fibrosis]])
** Late enhancement of contrast in conditions such as [[myocarditis]], [[sarcoidosis]], [[amyloidosis]], [[Anderson-Fabry disease|Anderson-Fabry]]'s disease, [[Chagas disease]])
| style="background: #F5F5F5; padding: 5px;" |
*Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
**[[S wave|S]]V1 or [[S wave|S]]V2 + [[R wave|R]]V5 or [[R wave|R]]V6 ≥3.5 mV
**Total [[QRS complex|QRS]] amplitude in each of the limb leads ≤0.8 mV
** [[R wave|R]]/[[S wave|S]] ratio <1 in lead V4
| style="background: #F5F5F5; padding: 5px;" |
*[[Cardiomegaly]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Previous [[myocardial infarction]]
*[[Hypertension]] ([[Systemic hypertension|systemic]] and [[Pulmonary hypertension|pulmonary]])
*[[Cardiac arrhythmia|Cardiac arrythmias]]
*[[Viral]] infections ([[myocarditis]])
*[[Congenital heart disease|Congenital heart defects]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Right heart failure]] associated with:
**[[Hepatomegaly]]
**Positive hepato-jugular reflex
**Increased [[jugular venous pressure]]
**[[Peripheral edema]]
*[[Left heart failure]] associated with:
**[[Pulmonary edema]]
**Eventual [[right heart failure]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Percarditis]]
| style="background: #F5F5F5; padding: 5px;" |
*On contrast enhanced [[Computed tomography|CT scan]]:
**Enhancement of the [[pericardium]] (due to [[inflammation]])
**[[Pericardial effusion]]
**[[Pericardial calcification]]
*On [[gadolinium]]-enhanced fat-saturated [[Magnetic resonance imaging|T1-weighted MRI]]:
**[[Pericardial]] enhancement (due to [[inflammation]])
**[[Pericardial effusion]]
| style="background: #F5F5F5; padding: 5px;" |
*ST elevation
*PR depression
| style="background: #F5F5F5; padding: 5px;" |
*Large collection of fluid inside the pericardial sac (pericardial effusion)
*Calcification of pericardial sac
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔ (Low grade)
| style="background: #F5F5F5; padding: 5px;" |✔ (Relieved by sitting up and leaning forward)
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Infections:
**[[Viral]] (Coxsackie virus, [[Herpes simplex virus|Herpes virus]], [[Mumps virus]], [[Human Immunodeficiency Virus (HIV)|HIV]])
**[[Bacteria]] ([[Mycobacterium tuberculosis]]-common in developing countries)
**[[Fungal]] ([[Histoplasmosis]])
*Idiopathic in a large number of cases
*[[Autoimmune]]
*[[Uremia]]
*[[Malignancy]]
*Previous [[myocardial infarction]]
| style="background: #F5F5F5; padding: 5px;" |
*May be clinically classified into:
**Acute (< 6 weeks)
**Sub-acute (6 weeks - 6 months)
**Chronic (> 6 months)
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumonia]]
| style="background: #F5F5F5; padding: 5px;" |
*On [[Computed tomography|CT scan]]: (not generally indicated)
**[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar pneumonia)
**Peribronchial [[nodules]] ([[bronchopneumonia]])
**[[Ground glass opacification on CT|Ground-glass opacity]] (GGO)
**[[Abscess]]
**[[Pleural effusion]]
**On [[MRI]]:
*Not indicated
| style="background: #F5F5F5; padding: 5px;" |
*Prolonged [[PR interval]]
*Transient [[T wave]] inversions
| style="background: #F5F5F5; padding: 5px;" |
*[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar [[pneumonia]])
*Peribronchial [[nodules]] (bronchopneumonia)
*Ground-glass opacity (GGO)
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Ill-contact
*Travelling
*[[Smoking]]
*[[Diabetes mellitus|Diabetic]]
*Recent hospitalization
*[[Chronic obstructive pulmonary disease]]
| style="background: #F5F5F5; padding: 5px;" |
*Requires [[Sputum|sputum stain]] and culture for diagnosis
*[[Empiric therapy|Empiric management]] usually started before [[Culture collection|culture]] results
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Vasculitis]]
| style="background: #F5F5F5; padding: 5px;" |
*On [[Computed tomography|CT scan]]: ([[Takayasu's arteritis|Takayasu arteritis]])
**[[Blood vessel|Vessel]] wall thickening
**Luminal narrowing of [[pulmonary artery]]
**Masses or nodules ([[Anti-neutrophil cytoplasmic antibody|ANCA]]-associated granulomatous vasculitis)
*On [[Magnetic resonance imaging|MRI]]:
Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Bundle branch block|Right or left bundle-branch block]] ([[Churg-Strauss syndrome]])
*[[Atrial fibrillation]] ([[Churg-Strauss syndrome]])
*Non-specific [[ST interval|ST segment]] and [[T wave]] changes
| style="background: #F5F5F5; padding: 5px;" |
*[[Nodule (medicine)|Nodules]]
*[[Cavitation]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*[[Takayasu's arteritis|Takayasu arteritis]] usually found in persons aged 4-60 years with a mean of 30
*[[Giant-cell arteritis]] usually occurrs in persons aged > 60 years
*[[Churg-Strauss syndrome]] may present with [[asthma]], [[sinusitis]], transient [[pulmonary]] infiltrates and neuropathy alongwith [[cardiac]] involvement
*Granulomatous vasculitides may present with [[nephritis]] and [[upper airway]] ([[nasopharyngeal]]) destruction
| style="background: #F5F5F5; padding: 5px;" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic obstructive pulmonary disease]] (COPD)
| style="background: #F5F5F5; padding: 5px;" |
*On [[Computed tomography|CT scan]]:
**[[Chronic bronchitis]] may show [[bronchial]] wall thickening, scarring with bronchovascular irregularity, [[fibrosis]]
**[[Emphysema]] may show [[alveolar]] septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe)
**Giant bubbles
*On [[MRI]]:
**Increased diameter of [[pulmonary arteries]]
**Peripheral [[pulmonary]] [[vasculature]] attentuation
**Loss of retrosternal airspace due to right ventricular enlargement
**Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung
| style="background: #F5F5F5; padding: 5px;" |
*[[Multifocal atrial tachycardia]] (atleast 3 distinct [[P waves|P wave]] morphologies)
| style="background: #F5F5F5; padding: 5px;" |
*Enlarged [[lung]] shadows ([[emphysema]])
*Flattening of [[diaphragm]] ([[emphysema]])
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Smoking]]
*[[Alpha 1-antitrypsin deficiency|Alpha-1 antitrypsin deficiency]]
*Increased [[sputum]] production ([[chronic bronchitis]])
*[[Cough]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Alpha 1-antitrypsin deficiency|Alpha 1 antitrypsin deficiency]] may be associated with [[hepatomegaly]]
|}


=====Other Conditions that Cause Dyspnea that are Emergencies=====
=====Other Conditions that Cause Dyspnea that are Emergencies=====

Revision as of 14:21, 16 October 2017



Resident
Survival
Guide
Congestive Heart Failure Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure differential diagnosis On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Congestive heart failure differential diagnosis

CDC on Congestive heart failure differential diagnosis

Congestive heart failure differential diagnosis in the news

Blogs on Congestive heart failure differential diagnosis

Directions to Hospitals Treating Congestive heart failure differential diagnosis

Risk calculators and risk factors for Congestive heart failure differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Congestive heart failure should be distinguished from other conditions that cause dyspnea, fatigue and edema.

Differentiating Congestive Heart Failure from other Diseases

Heart failure is a clinical syndrome of dyspnea, fatigue and edema. There are several disorders that cause heart failure and should not be confused with the syndrome of heart failure.


Organ System Disease Symptoms Signs Laboratory findings Diagnostic modality Management
Cardiac HFpEF Exertional dyspnea, reduced exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, edema Elevated JVP, fine crackles, edema Increased BNP Echocardiography (normal EF) Control of volume overload and hypertension,

treatment of underlying condition (obesity, AF, coronary artery disease, anemia)

HFrEF Exertional dyspnea, reduced exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, edema Elevated JVP, fine crackles, edema Increased BNP Echocardiography (reduced EF) Diuretics, ACE inhibitors, ARBs, beta blockers, nitrates
Pericardial disease Exercise intolerance, dyspnea, fatigue Elevated JVP, pericardial knock, kussmaul's sign, pulsus paradoxus - Echocardiography, ECG Diuretics, pericardiectomy
Hypertrophic cardiomyopathy Dyspnea, chest pain, palpitation, lightheadedness Systolic murmur - Echocardiography, ECG Beta blockers, verapamil
Valvular disease (MR, TR) Edema, fatigue, exercise intolerance, dyspnea, lightheadedness Cardiac murmur - Echocardiography, ECG Valve repair or replacement, diuretics, beta blockers
Arrhythmia Palpitation, lightheadedness, chest tightness Tachycardia, abnormal pulse - Echocardiography, ECG, holter monitoring Pharmacological cardioversion (anti arrhythmics), electrical cardioversion, ablation
Pulmonary Chronic airway disease Cough, dyspnea, chest pain, exercise intolerance Tachypnea, respiratory distress, cyanosis, edema, rhonchi and crackles Hypoxemia, hypercapnea, polycythemia, PFT, chest imaging Bronchodilators, corticosteroids, anticholinergics
Interstitial lung diseaee Exercise intolerance, cough Crackles, clubbing, cyanosis Hypoxemia PFT, Chest imaging, lung biopsy Corticosteroids, bronchodilators
Pulmonary hypertension Dyspnea, fatigue, chest pain, syncope, palpitation Edema, clubbing, elevated JVP, TR murmur Elevated BNP, elevated d-dimer Echocardiography, cardiac cathaterization Diuretics, calcium channel blockers, endothelin receptor antagonist, phosphodiesterase 5 inhibitor
Sleep apnea Snoring, somnolence, headache, fatigue, irritability tachypnea, hypertension, tachycardia Hypoxemia, polycythemia Polysomnography Weight reduction, CPAP
High output status Anemia Palpitation, lightheadedness, fatigue Cheilosis, delayed capillary refill Decreased Hb and HCT CBC, Iron study, bone marrow aspiration and biopsy Iron replacement, nutritional support
Thyrotoxicosis Palpitation, sweating, weight loss Proptosis, tachycardia Decreased TSH, increased T3,T4 Thyroid function test Thyrostatics, beta blockers, ablation
Others Liver disease Fatigue, edema, jaundice Ascites, palmar erythema, gynecomastia Increased AST and ALT, decreased albumin, increased Br Liver function test, Liver biopsy Diuretics, treatment of underlying disease
Chronic kidney disease Fatigue, anorexia, nausea, edema, decreased exercise tolerance Edema, hypertension, crackles Increased BUN and Cr BUN, Cr Control of blood pressure, anemia, dialysis, kidney transplant


Other Causes of Dyspnea

There are non-cardiac causes of edema that primarily involve the lung or respiratory system. These conditions are distinguished from heart failure in so far as they do not cause peripheral edema, and they are not be associated with an elevation in BNP. CHF should be differentiated from other diseases presenting with shortness of breath and tachypnea. The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
CT scan and MRI EKG Chest X-ray Tachypnea Tachycardia Fever Chest Pain Hemoptysis Dyspnea on Exertion Wheezing Chest Tenderness Nasalopharyngeal Ulceration Carotid Bruit
Pulmonary embolism
  • On CT angiography:
    • Intra-luminal filling defect
  • On MRI:
    • Narrowing of involved vessel
    • No contrast seen distal to obstruction
    • Polo-mint sign (partial filling defect surrounded by contrast)
✔ (Low grade) ✔ (In case of massive PE) - - - -
Congestive heart failure
  • Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
    • SV1 or SV2 + RV5 or RV6 ≥3.5 mV
    • Total QRS amplitude in each of the limb leads ≤0.8 mV
    • R/S ratio <1 in lead V4
- - - - - -
Percarditis
  • ST elevation
  • PR depression
  • Large collection of fluid inside the pericardial sac (pericardial effusion)
  • Calcification of pericardial sac
✔ (Low grade) ✔ (Relieved by sitting up and leaning forward) - - - - -
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks - 6 months)
    • Chronic (> 6 months)
Pneumonia - - - -
Vasculitis

Homogeneous, circumferential vessel wall swelling

-
Chronic obstructive pulmonary disease (COPD)
  • On CT scan:
  • On MRI:
    • Increased diameter of pulmonary arteries
    • Peripheral pulmonary vasculature attentuation
    • Loss of retrosternal airspace due to right ventricular enlargement
    • Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung
- - - - - -
Other Conditions that Cause Dyspnea that are Emergencies

The following emergency conditions should be excluded when diagnosing a patient with heart failure:

Non Cardiac Causes of Dyspnea

Other Causes of Fatigue

There are numerous non-cardiac causes of fatigue. Again, these non-cardiac causes are not associated with dyspnea and edema.

Other Causes of Edema

Other non cardiac causes of pedal edema are listed below. Obviously, the majority of these disorders do not also cause dyspnea and fatigue, and that distinguishes them form heart failure.

References

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  2. "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".
  3. Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
  4. "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".
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  6. Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). "Symptom distress and quality of life in patients with advanced congestive heart failure". J Pain Symptom Manage. 35 (6): 594–603. doi:10.1016/j.jpainsymman.2007.06.007. PMC 2662445. PMID 18215495.
  7. Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). "Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology". Eur. J. Heart Fail. 11 (2): 130–9. doi:10.1093/eurjhf/hfn013. PMC 2639415. PMID 19168510.
  8. Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.
  9. Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.
  10. Nakawah MO, Hawkins C, Barbandi F (2013). "Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome". J Am Board Fam Med. 26 (4): 470–7. doi:10.3122/jabfm.2013.04.120256. PMID 23833163.
  11. Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). "Pericardial disease: diagnosis and management". Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
  12. Bogaert J, Francone M (2013). "Pericardial disease: value of CT and MR imaging". Radiology. 267 (2): 340–56. doi:10.1148/radiol.13121059. PMID 23610095.
  13. Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.
  14. Schmidt WA (2013). "Imaging in vasculitis". Best Pract Res Clin Rheumatol. 27 (1): 107–18. doi:10.1016/j.berh.2013.01.001. PMID 23507061.
  15. Suresh E (2006). "Diagnostic approach to patients with suspected vasculitis". Postgrad Med J. 82 (970): 483–8. doi:10.1136/pgmj.2005.042648. PMC 2585712. PMID 16891436.
  16. Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.
  17. Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). "Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease". COPD. 10 (1): 62–71. doi:10.3109/15412555.2012.727918. PMID 23413894.
  18. Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). "Electrocardiogram in pneumonia". Am. J. Cardiol. 110 (12): 1836–40. doi:10.1016/j.amjcard.2012.08.019. PMID 23000104.
  19. Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). "Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis". Int. J. Cardiol. 199: 170–9. doi:10.1016/j.ijcard.2015.06.087. PMID 26209947.
  20. Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). "Cardiac involvement in Churg-Strauss syndrome". Arthritis Rheum. 62 (2): 627–34. doi:10.1002/art.27263. PMID 20112390.


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