Congestive heart failure differential diagnosis

Differential Diagnosis of Heart Failure

Heart Failure Secondary to Coronary Artery Disease

A. Underlying Mechanisms

1. Ischemic Preconditioning

   • Reductions in ischemia-related apoptosis
   • Increases in endogenous adenosine
   • Activation of potassium-adenosine triphosphate (K+-ATP) channels

2. Electrical Dysfunction

   • QT prolongation
   • Increased susceptibility to arrhythmia
   • QT dispersion

3. Mechanical Dysfunction

   • Systolic dysfunction
   • Diastolic dysfunction

4. Biochemical Dysfunction

   • Increases in beta-adrenergic receptor density
   • Changes in structural and regulatory proteins
   • Shift to FFA as a proffered metabolic substrate
   • Lactate production
   • Elevated BNP concentration

B. Utilisation of Clinical Data

Management of heart failure due to coronary artery disease are primarily influenced by following parameters:

1. An estimate of the relative proportions of:

   • Viable but ischemic myocardium
   • Nonviable myocardium
   • Viable non-ischemic myocardium

2. The technical feasibility of successful mechanical revascularization
3. The extent and severity of comorbidities in the individual patient

Cardiomyopathies and Inflammatory Diseases

Restrictive Cardiomyopathies

• Primary (idiopathic)
• Tumor infiltration
• Amyloidosis
• Storage diseases
• Endocardial fibrosis
• Anthracyclines
• Eosinophilic heart disease
• Radiation
• Hemochromatosis
• Cardiac transplant
• Sarcoidosis

Dilated Cardiomyopathies

• Duchenne muscular dystrophy
• Becker's muscular dystrophy
• Limb-girdle muscular dystrophy
• Mitochondrial myopathy

  • Kearns-Sayre syndrome

• Arrhythmogenic right ventricular dysplasia
• Alcohol-Induced cardiomyopathy
• Cocaine related cardiomyopathy
• Diabetic cardiomyopathy
• Peripartum cardiomyopathy
• Anthracycline induced cardiomyopathy
• Trastuzumab Herceptin-lnduced Cardiomyopathy

Inflammations

• Viral Myocarditis
• Rickettsial Myocarditis
• Bacterial Myocarditis
• Spirochetal Infections
• Protozoal Myocarditis: Trypanosomiasis (Chagas Disease)
• Fungal myocarditis
• Giant Cell Myocarditis
• Sarcoidosis

Congestive Heart Failure as a Consequence of Valvular Heart Disease

• Aortic stenosis with Left Ventricular Systolic Dysfunction
• Chronic aortic regurgitation
• Mitral Stenosis
• Chronic mitral regurgitation
• Acute aortic regurgitation
• Acute mitral regurgitation

Congestive Hert Failure Secondary to Congenital Heart Disease

A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases

• Eisenmenger's syndrome
• Fibrocalcific degeneration of abnormal aortic valve
• Systemic ventricular dysfunction and/or tricuspid regurgitation in congenitally corrected transposition of the great arteries
• Atrial septal defect with mitral regurgitation] secondary to myxomatous mitral valve
• Congenital mitral regurgitation
• Arrhythmia
• Endocarditis
• Other degenerative diseases (coronary artery disease, hypertension)
• Drug abuse, alcohol abuse
• Pregnancy

B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases

• Myocardial dysfunction
• Valvular regurgitation
• Persistent left-to-right shunt
• Pulmonary vascular disease
• Prosthetic valve dysfunction
• Status post Fontan operation
• Arrhythmia
• Endocarditis
• Other degenerative diseases (coronary artery disease, hypertension)

Right Ventricular Failure

Factors affected right ventricle and to be eliminated during management of congestive heart failure. A. Right ventricular myocardial dysfunction

1. Right ventricular myocardial infarction
2. Dilated cardiomyopathy
3. Right ventricular dysplasia

B. Primary right ventricular pressure overload

1. Left ventricular failure
2. Mitral valve disease
3. Atrial myxoma
4. Pulmonary veno-occlusive disease
5. Cor pulmonale

   • Chronic obstructive pulmonary disease
   • Primary pulmonary hypertension
   • Pulmonary embolism

6. Pulmonic stenosis

   • Supravalvular pulmonic stenosis
   • Valvular pulmonic stenosis
   • Subvalvular pulmonic stenosis

7. Ventricular septal defect
8. Aortopulmonary communication

C. Primary right ventricular volume overload

1. Pulmonic regurgitation
2. Tricuspid regurgitation
3. Atrial septal defect
4. Partial anomalous pulmonary venous return

D. Impediment to right ventricular inflow

1. Tricuspid stenosis
2. Cardiac tamponade
3. Constrictive pericarditis
4. Restrictive cardiomyopathy

Differential Diagnosis of Causes of Heart Failure

A. Left Ventricular Failure

Most Common Causes:

• Aortic regurgitation
• Aortic stenosis
• Hypertension
• Mitral regurgitation
• Myocardial ischemia

Expanded List of Causes:

• Atrial fibrillation
• Alcoholism
• Anemia
• Angina
• Aortic regurgitation
• Aortic Stenosis
• Arteriovenous fistula
• Beriberi
• Cardiac aneurysm
• Cardiomyopathy
• Constrictive pericarditis
• Drugs, toxins
• Hypertension
• Hyperthyroidism
• Hypovolemia
• Hypoxia
• Mediastinal tumors
• Mitral Regurgitation
• Myocardial Infarction
• Paget's Disease
• Pancoast's Tumor
• Pericardial effusion
• Pericardial tamponade
• Perimyocarditis
• Protein deficiency
• Restrictive cardiomyopathy
• Rupture of the papillary muscles
• Sepsis
• Vena Cava Superior Thrombosis

B. Right Ventricular Failure

Most Common Causes:

• Cardiomyopathy
• Cor pulmonale
• Diffuse myocarditis
• Left heart failure

Other Causes:

• After left ventricular failure
• After pulmonary resection
• Allergic alveolitis
• Bronchial asthma
• Chronic bronchitis
• Honeycomb lung
• Hyperglobulia
• Emphysema
• Mitral Stenosis
• Right ventricular myocardial infarction
• Pickwickian Syndrome
• Pleural fibrosis
• Pneumoconiosis
• Pulmonary fibrosis
• Pulmonic regurgitation
• Pulmonic stenosis
• Sarcoidosis
• Severe relapsing pulmonary emboli
• Silicosis
• Tachycardia
• Tricuspid insufficiency

C. Others

• Ascorbic acid deficiency
• Cardiac amyloidosis
• Carnitine deficiency
• Cervical vein stasis of non-cardiac genesis
• Congenital heart disease
• Cyanosis of non-cardiac genesis
• Diabetes Mellitus
• Dyspnea of non-cardiac genesis
• Edema of non-cardiac genesis
• Hemochromatosis
• Pleural effusion of non-cardiac genesis
• Pulmonary edema of non-cardiac genesis
• Thiamine deficiency
• Thyroid disease