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]Syed Hassan A. Kazmi BSc, MD [3]

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.
• 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.

Organ System	Disease	Symptoms	Signs	Laboratory findings	Diagnostic modality	Management
Cardiac	HFpEF (Heart Failure with preserved ejection fraction)	Exertional dyspnea, reduced exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, edema	Elevated JVP, fine crackles, edema	Increased BNP	Echocardiography (EF ≥ 50 %)	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 (EF ≤ 40 %)	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

CHF should be differentiated from other diseases presenting with shortness of breath and tachypnea. The differentials include the following:

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)	S1Q3T3 pattern representing acute right heart strain	Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign	✔	✔	✔ (Low grade)	✔	✔ (In case of massive PE)	✔	-	-	-	-	Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy)	May be associated with metabolic alkalosis and syncope
Congestive heart failure	On CT scan: Mediastinal lymphadenopathy Hazy mediastinal fat On MRI: Abnormality of cardiac chambers (hypertrophy, dilation) Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis) Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, amyloidosis, Anderson-Fabry's disease, Chagas disease)	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	Cardiomegaly	✔	✔	✔	-	-	✔	-	-	-	-	Previous myocardial infarction Hypertension (systemic and pulmonary) Cardiac arrythmias Viral infections (myocarditis) Congenital heart defects	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
Percarditis	On contrast enhanced CT scan: Enhancement of the pericardium (due to inflammation) Pericardial effusion Pericardial calcification On gadolinium-enhanced fat-saturated T1-weighted MRI: Pericardial enhancement (due to inflammation) Pericardial effusion	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)	-	✔	-	-	-	-	Infections: Viral (Coxsackie virus, Herpes virus, Mumps virus, HIV) Bacteria (Mycobacterium tuberculosis-common in developing countries) Fungal (Histoplasmosis) Idiopathic in a large number of cases Autoimmune Uremia Malignancy Previous myocardial infarction	May be clinically classified into: Acute (< 6 weeks) Sub-acute (6 weeks - 6 months) Chronic (> 6 months)
Pneumonia	On CT scan: (not generally indicated) Consolidation (alveolar/lobar pneumonia) Peribronchial nodules (bronchopneumonia) Ground-glass opacity (GGO) Abscess Pleural effusion On MRI: Not indicated	Prolonged PR interval Transient T wave inversions	Consolidation (alveolar/lobar pneumonia) Peribronchial nodules (bronchopneumonia) Ground-glass opacity (GGO)	✔	✔	✔	✔	-	✔	✔	-	-	-	Ill-contact Travelling Smoking Diabetic Recent hospitalization Chronic obstructive pulmonary disease	Requires sputum stain and culture for diagnosis Empiric management usually started before culture results
Vasculitis	On CT scan: (Takayasu arteritis) Vessel wall thickening Luminal narrowing of pulmonary artery Masses or nodules (ANCA-associated granulomatous vasculitis) On MRI: Homogeneous, circumferential vessel wall swelling	Right or left bundle-branch block (Churg-Strauss syndrome) Atrial fibrillation (Churg-Strauss syndrome) Non-specific ST segment and T wave changes	Nodules Cavitation	✔	✔	✔	✔	✔	✔	-	✔	✔	✔	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
Chronic obstructive pulmonary disease (COPD)	On 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	Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies)	Enlarged lung shadows (emphysema) Flattening of diaphragm (emphysema)	✔	✔	-	-	-	✔	✔	-	-	-	Smoking Alpha-1 antitrypsin deficiency Increased sputum production (chronic bronchitis) Cough	Alpha 1 antitrypsin deficiency may be associated with hepatomegaly
COVID-19-associated heart failure	CT: Cardiomegaly, Pulmonary edema CMR: Signs of underlying myocarditis may be seen.	Left ventricular hypertrophy Low-voltage QRS Non-specific ST-T change	Cardiomegaly Pulmonary edema (interstitial, alveolar)	✔	✔	-	-	✔	✔	-	-	-	-	-	Increased NT-proBNP and cardiac troponins levels

Other Conditions that Cause Dyspnea that are Emergencies

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

• Asthma or bronchospasm
• Foreign body aspiration
• H. influenza epiglottitis
• Spontaneous pneumothorax

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