Heart Failure Differential Diagnoses

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Heart Failure Differential
Diagnoses
Updated: Mar 02, 2021
Author: Ioana Dumitru, MD; Chief Editor: Gyanendra K Sharma, MD, FACC, FASE more...
DDX
Diagnostic Considerations
Many classes of disorders can result in increased cardiac demand or impaired cardiac function.
Cardiac causes include arrhythmias (tachycardia or bradycardia), structural heart disease, and
myocardial dysfunction (systolic or diastolic). Noncardiac causes include processes that increase
the preload (volume overload), increase the afterload (hypertension), reduce the oxygen-carrying
capacity of the blood (anemia), or increase demand (sepsis). For example, renal failure can result
in heart failure due to fluid retention and anemia. Lymphatic obstruction and venous obstruction
syndromes can also cause edema-forming states, and obesity-hypoventilation syndrome (OHS)
can lead to right-sided heart failure with right ventricular hypertrophy.
Diastolic heart failure may be the most common form of heart failure in the US population.
[21]
Alterations in ventricular-arterial coupling appear to have a key role in impaired hemodynamic
response to exercise, but the diagnosis of diastolic heart failure cannot be excluded even in the
presence of normal diastolic function at rest.
[21]
Cardiogenic and noncardiogenic pulmonary edema

Heart failure should also be differentiated from the pulmonary edema that is associated with injury
to the alveolar-capillary membrane caused by diverse etiologies (ie, noncardiogenic pulmonary
edema, adult respiratory distress syndrome [ARDS]). Increased capillary permeability is observed
in trauma, hemorrhagic shock, sepsis, respiratory infections, administration of various drugs, and
ingestion of toxins (eg, heroin, cocaine, toxic gases). With the advent of natriuretic peptide testing,
differentiating cardiac from noncardiac causes of pulmonary edema has improved.
[61, 62]
Several features may differentiate cardiogenic from noncardiogenic pulmonary edema. In heart
failure, a history of an acute cardiac event or of progressive symptoms of heart failure is usually
present. The physical examination may yield clues to acute heart failure. Findings such as an S3
gallop and elevated jugular venous pulsation are highly specific for acute heart failure, but their low
sensitivity makes them less-than-ideal screening tools.
[55, 63]
Patients with noncardiogenic pulmonary edema may have clinical features similar to those with
cardiogenic pulmonary edema but will often lack an S3 gallop and jugular venous distention. The
differentiation is often made based on pulmonary capillary wedge pressure (PCWP) measurements
from invasive hemodynamic monitoring. Left ventricular filling pressures measured by PCWP are
the single most reliable hemodynamic measure that predicts a fatal outcome in patients with acute
heart failure. PCWP is generally more than 18 mm Hg in heart failure and less than 18 mm Hg in
noncardiogenic pulmonary edema, but superimposition of chronic pulmonary vascular disease can
make this distinction more difficult to discern.
Atypical presentations
Heart failure, in particular right-sided heart failure, can present as an abdominal syndrome with
nausea, vomiting, right-sided abdominal pain (as a sign of liver congestion), bloating, anorexia, and
significant weight loss. In advanced cases, patients can appear jaundiced because of cardiac
cirrhosis. Constipation is a common complaint among patients with heart failure, and it can be a
manifestation of decreased intestinal transit secondary to poor perfusion. In very severe cases of
cardiogenic shock, an individual can present with severe abdominal pain mimicking bowel
obstruction, perforation, acute abdomen, and peritonitis as a manifestation of severe intestinal
ischemia and possible infarction.
In elderly patients, fatigue and confusion can sometimes be the first symptoms of heart failure,
which is related to a decrease in cardiac output. The mnemonic DEFEAT-HF consists of five steps
that may be helpful in the diagnosis and management of heart failure in the older population:
diagnosis, etiology, fluid volume, ejection fraction, and therapy.
[54]
Differential Diagnoses
Acute Kidney Injury
Acute Respiratory Distress Syndrome (ARDS)
Bacterial Pneumonia
Cardiogenic Pulmonary Edema
Chronic Obstructive Pulmonary Disease (COPD)
Cirrhosis
Community-Acquired Pneumonia (CAP)
Emphysema
Goodpasture Syndrome
Idiopathic Pulmonary Fibrosis (IPF)
Interstitial (Nonidiopathic) Pulmonary Fibrosis
Myocardial Infarction
Nephrotic Syndrome
Neurogenic Pulmonary Edema
Pneumothorax Imaging
Pulmonary Embolism (PE)
Respiratory Failure
Venous Insufficiency
Viral Pneumonia
Workup

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This site is intended for healthcare professionals

Cardiogenic and noncardiogenic pulmonary edema

Acute Respiratory Distress Syndrome (ARDS)

Cardiogenic Pulmonary Edema

Chronic Obstructive Pulmonary Disease (COPD)

Community-Acquired Pneumonia (CAP)

Idiopathic Pulmonary Fibrosis (IPF)

Interstitial (Nonidiopathic) Pulmonary Fibrosis

Neurogenic Pulmonary Edema

Pulmonary Embolism (PE)

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