Congestive heart failure differential diagnosis

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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]


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 (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 (Heart Failure with reduced Ejection Fraction) 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:[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
- - - - - -
  • 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 - - - -

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
- - - - - -
COVID-19-associated heart failure - - - - - - -
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.


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