Heart Failure Differential Diagnoses

Updated: Jun 05, 2023
  • Author: Ioana Dumitru, MD; Chief Editor: Gyanendra K Sharma, MD, FACC, FASE  more...
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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. [25] 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. [25]

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. [65, 66]

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. [59, 67]

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. [58]

Differential Diagnoses