Congestive heart failure differential diagnosis
 |
Resident Survival Guide |
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.
- Cardiac arrest and asystole refer to situations in which there is no cardiac output at all. Without urgent treatment these result in sudden death.
- Myocardial infarction ("Heart attack") refers to heart muscle damage due to an insufficient blood supply to the heart, usually as a result of a blocked coronary artery.
- Cardiomyopathy refers specifically to problems within the heart muscle, and these problems can result in heart failure. Ischemic cardiomyopathy implies that the cause of muscle damage is coronary artery disease. Dilated cardiomyopathy implies that the muscle damage has resulted in enlargement of the heart. Hypertrophic cardiomyopathy involves enlargement and thickening of the heart muscle.
| 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 |
|
|
|
✔ | ✔ | ✔ (Low grade) | ✔ | ✔ (In case of massive PE) | ✔ | - | - | - | - |
|
|
| Congestive heart failure |
|
✔ | ✔ | ✔ | - | - | ✔ | - | - | - | - |
|
| ||
| Percarditis |
|
|
|
✔ | ✔ | ✔ (Low grade) | ✔ (Relieved by sitting up and leaning forward) | - | ✔ | - | - | - | - |
|
|
| Pneumonia |
|
|
|
✔ | ✔ | ✔ | ✔ | - | ✔ | ✔ | - | - | - |
|
|
| Vasculitis |
|
|
✔ | ✔ | ✔ | ✔ | ✔ | ✔ | - | ✔ | ✔ | ✔ |
|
||
| Chronic obstructive pulmonary disease (COPD) |
|
|
✔ | ✔ | - | - | - | ✔ | ✔ | - | - | - |
|
| |
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
- Abdominal masses
- Acute bronchitis
- Acute Chest Syndrome
- Acute myeloid leukemia
- Acute promyelocytic leukemia
- Acute tracheobronchitis
- AIDS
- Air pollution
- Air-conditioner lung
- Allergy
- Alpha 1-antitrypsin deficiency
- Altitude sickness
- Amniotic fluid embolism
- Amphotericin B
- Amyl nitrite
- Amyotrophic Lateral Sclerosis (ALS)
- Anaphylactoid reactions
- Anaphylaxis
- Anemia
- Anthrax
- Anxiety
- Asbestosis
- Aspergillus clavatus
- Aspiration
- Asthma
- Atelectasis
- Atypical pneumonia
- Barium
- Beta-blockers
- Betazole
- Bird breeder's lung
- Bird fancier's lung
- Bland-White-Garland Syndrome
- Bleomycin in ABVD
- Blood transfusion
- Brain stem infarction
- Bronchial asthma
- Bronchial tumors
- Bronchiolitis
- Bronchiolitis obliterans
- Bronchiolitis obliterans organizing pneumonia
- Bronchitis
- Bronchogenic carcinoma
- Bronchoscopy
- Cardiovascular syphilis
- Caspofungin
- Cheese worker's lung
- Chemical worker's lung
- Chest trauma
- Chest tube
- Cholesterol pericarditis
- Chronic bronchitis
- Chronic fatigue syndrome
- Chronic Obstructive Pulmonary Disease (COPD)
- Chylothorax
- Cirrhosis
- Cladosporium
- CMV Pneumonitis
- Community-acquired pneumonia
- Croup
- Cystic Fibrosis
- Daptomycin
- Decompression sickness
- Decreased thoracic or diaphragmatic excursion
- Diabetic coma
- Diffuse panbronchiolitis
- Diverticulosis
- Drugs
- Ehrlichiosis (canine)
- Empty nose syndrome
- Empyema, pleural
- Encephalitis
- Eosinophilic pneumonia
- Ephedrine
- Epidemic dropsy
- Erdheim-Chester disease
- Esophageal cancer
- Esophageal diseases with tracheal compression
- Exercise-induced asthma
- Extrinsic allergic alveolitis
- Fat embolism
- Fibrosing alveolitis, cryptogenic
- Gamma-Hydroxybutyric acid
- Gastroesophageal reflux
- Gemeprost
- Glatiramer acetate
- Glottal edema
- Goiter
- Goodpasture syndrome
- Grain handler's lung
- Gram-negative sepsis
- Guillain-Barre Syndrome
- Hemochlyothorax
- Hemothorax
- Histiocytosis X
- Hoose (disease)
- Humidifier lung
- Hydrochlyothorax
- Hypersensitivity Pneumonitis
- Hyperthyroidism
- Hypoxia
- Hysteria
- Idiopathic pulmonary fibrosis
- Iloprost
- Interstitial lung disease
- Intoxication (carbon monoxide, cyanide)
- Intrapulmonary receptor stimulation
- Intussusception (medical disorder)
- Iron deficiency anemia
- Irregular Heart Rhythms
- Ketorolac
- Kyphoscoliosis
- Laryngeal/bronchospasm
- Leukemia
- Lung cancer
- Lymphangitic metastases
- Lymphocytic interstitial pneumonia
- Lymphoma
- Malignant Mesothelioma
- Malt worker's lung
- Mediastinal tumors
- Megaloblastic Anemias
- Mercury (element)
- Metabolic acidosis
- Methyl isocyanate
- Micropolyspora faeni
- Miliary tuberculosis
- Mollusk shell hypersensitivity
- Mucor stolonifer
- Multiple rib fractures
- Myasthenia Gravis
- Myxoma
- Neuromuscular disease
- Obesity
- Phrenic nerve paralysis
- Pleural callosity
- Pneumoconiosis
- Pneumonia
- Pneumochlyothorax
- Pneumothorax
- Pleural Effusion
- Pleural fibrosis
- Polyradiculitis
- Pulmonary arteriovenous malformation
- Pulmonary Emphysema
- Pulmonary fibrosis
- Quincke's Edema
- Radiation pneumonitis
- Respiratory tract infection
- Sarcoidosis
- Shock
- Shock lung
- Sleep Apnea Syndrome
- Trauma
- Tracheal stenosis
- Tracheal tumors
- Tracheomalacia
- Tracheobronchial collapse
- Uremia
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.
- ACE inhibitor
- Aceon
- Acquired C1-esterase inhibitor deficiency
- Actos
- Acute glomerulonephritis
- Addison's Disease
- Aldomet
- Amlodipine
- Amniotic band
- Angioneurotic edema
- Angiotensin converting enzyme inhibitor
- Anemia
- Anorexia Nervosa
- AV fistula
- Avandia
- Bartter's Syndrome
- Beta blockers
- Boils
- Bruise
- Bulimia Nervosa
- Burn
- Cachexia
- Carbuncle
- Cardura
- Cellulitis
- Chemotherapy
- Cisplatin
- Cold (physical stimuli)
- Contact dermatitis
- Contusion
- Cushing's Syndrome
- Diltiazem
- Drugs
- Docetax
- Erysipelas
- Exudative enteropathy
- Filariasis
- Fracture
- Frostbite
- Gas gangrene
- Glitazones
- Gout
- Hyperthyroidism
- Hypoalbuminemia
- Hypoplasia
- Hypothyroidism
- Ibuprophen
- Idiopathic edema
- Insect bite
- Irritant
- Ligamentous sprain
- Liver failure
- Lymph node mass
- Malabsorption
- Malnutrition
- Mediastinal cancer
- Milroy's Disease
- Minipress
- Motrin
- Musculoskeletal trauma
- Neoplasm
- Nephrotic Syndrome
- Nifedipine
- Norvasc
- Osteomyelitis
- Peripheral nerve lesion
- Premenstrual edema
- Scleroderma
- Sepsis syndrome
- Snakebites
- Starvation edema
- Sunburn
- Surgical excision
- Tendonous strain
- Thrombophlebitis
- Thrombosis
- Tight clothing
- Trentinion
- Trichinosis
- Tumors
- Univasc
- Valproic acid
- Varicose veins
- Vesinoid
- vytorin
References
- ↑ Brenes-Salazar JA (2014). "Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era". J Emerg Trauma Shock. 7 (1): 57–8. doi:10.4103/0974-2700.125645. PMC 3912657. PMID 24550636.
- ↑ "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".
- ↑ 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.
- ↑ "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".
- ↑ Ramani GV, Uber PA, Mehra MR (2010). "Chronic heart failure: contemporary diagnosis and management". Mayo Clin. Proc. 85 (2): 180–95. doi:10.4065/mcp.2009.0494. PMC 2813829. PMID 20118395.
- ↑ 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.
- ↑ 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.
- ↑ Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.
- ↑ Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.