Differentials
Aging/physical inactivity
SIGNS / SYMPTOMS
Aging, deconditioning, and/or obesity may cause a reduction in effort tolerance due to dyspnea and/or fatigue, but without the additional major and minor criteria for diagnosing HF.
INVESTIGATIONS
Elucidation of the precise reason for exercise intolerance can be difficult because several disorders may coexist in the same patient. Echocardiography in HF shows characteristic signs of HF. However, a clear distinction can sometimes be made only by measurements of gas exchange or blood oxygen saturation or by invasive hemodynamic measurements during graded levels of exercise (i.e., cardiopulmonary exercise test with VO₂ max).
COPD/pulmonary fibrosis
SIGNS / SYMPTOMS
Dyspnea may be episodic, with or without environmental triggers, and is usually accompanied by cough, wheezing, sputum, and a history of smoking or industrial exposure.
INVESTIGATIONS
Pulmonary function tests will give definite diagnosis of an obstructive or restrictive pulmonary disease. Plasma B-type natriuretic peptide levels may be intermediate (100-400 picograms/mL) in COPD.
Pneumonia
SIGNS / SYMPTOMS
Patients may present with fever, cough, and productive sputum, with focal signs of consolidation (increased vocal fremitus and bronchial breathing).
INVESTIGATIONS
CXR may show signs of consolidation. CBC may show elevated WBC, and blood cultures may be positive for the etiologic organism.
Pulmonary embolism (PE)
SIGNS / SYMPTOMS
Sudden onset of chest pain, dyspnea, and hemoptysis, especially after childbirth, are suggestive of PE.[117] Dyspnea with or without chest pain may be present in other conditions associated with venous thrombosis and PE (e.g., cancer, prolonged immobilization, postoperative state).
INVESTIGATIONS
ECG is abnormal in the majority of patients with PE and may show a deep S wave in lead I and a deep Q wave and T-wave inversion in lead III (S1-Q3-T3). Other common changes include sinus tachycardia, complete or incomplete right bundle-branch block, and T-wave inversion in the inferior (II, III, aVF) or the anterior leads (V1 to V4).
Normal levels of D-dimers can help to exclude PE, but elevated levels occur in other conditions (e.g., aortic dissection and many types of cardiomyopathies) as well as in PE.
Postpartum cardiomyopathy (PPCM)
SIGNS / SYMPTOMS
Patients most commonly present with dyspnea, but other frequent complaints include cough, orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, and chest discomfort, which are also common symptoms of PE.[117] PPCM is defined on the basis of 4 criteria: 1) development of cardiac failure in the last month of pregnancy or within 5 months of delivery; 2) absence of an identifiable cause for the cardiac failure; 3) absence of recognizable heart disease before the last month of pregnancy; 4) left ventricular systolic dysfunction shown on echocardiograph. A number of potential risk factors may point to the diagnosis of PPCM, including age >30 years, multiparity, women of African descent, pregnancy with multiple fetuses, a history of preeclampsia/eclampsia/postpartum hypertension, and maternal cocaine misuse.
INVESTIGATIONS
In the presence of elevated D-dimers (commonplace in pregnancy) and positive risk factors for thromboembolic events, echocardiography will identify the underlying left ventricular systolic dysfunction and point to the diagnosis of PPCM. It usually shows left ventricular enlargement and significant global reduction in ejection fraction. Other findings may include left atrial enlargement, mitral and tricuspid regurgitation, and a small pericardial effusion.
Cirrhosis
SIGNS / SYMPTOMS
Typically causes jaundice, fatigue, nausea, peripheral edema, ascites, bruising and prolonged bleeding, gynecomastia, and hematemesis.
INVESTIGATIONS
LFTs are abnormal. Ultrasound or CT scan may detect ascites and liver abnormalities. Liver biopsy shows characteristic cirrhotic changes and may reveal the underlying cause.
Nephrotic syndrome
SIGNS / SYMPTOMS
Typically causes peripheral edema, fatigue, dyspnea, and loss of appetite.
INVESTIGATIONS
Urinalysis shows proteinuria, and serum albumin is reduced. Twenty-four-hour urine collection shows >3.5 g protein. BUN and creatinine clearance may be abnormal in later stages. Serum cholesterol and triglyceride levels may be elevated. Kidney ultrasound and biopsy may reveal the underlying cause.
Pericardial disease
SIGNS / SYMPTOMS
May present with chest pain, typically worse on lying down, swallowing, or coughing; tachycardia; dyspnea; cough; edema; fatigue; and low-grade fever. Pericardial friction rub may be heard at the left sternal border or apex.
INVESTIGATIONS
ECG may show electrical alternans (in large pericardial effusion) or ST elevation and T wave flattening or inversion (in pericarditis). Echocardiography may detect pericardial effusion, tamponade, and pericardial fibrosis. CT scan or MRI may show thickened pericardium. Pericardial biopsy may reveal the underlying cause.
Venous stasis
SIGNS / SYMPTOMS
Edema affects lower limbs only, and varicose veins may be present. Skin over the lower legs may be darkened, with ulceration.
INVESTIGATIONS
Doppler examination may detect incompetent valves in varicose veins.
Deep venous thrombosis
SIGNS / SYMPTOMS
Typically causes pain, swelling, and tenderness of one calf, which becomes red and warm.
INVESTIGATIONS
D-dimer test may be positive. Ultrasound scan or contrast venography may detect an area of thrombosis.
Cardiac amyloidosis
SIGNS / SYMPTOMS
No differentiating signs or symptoms. Patient may have an underlying condition (e.g., multiple myeloma).
INVESTIGATIONS
Investigations include screening for monoclonal light chains by serum and urine immunofixation electrophoresis and serum free light chains.[7] Bone scintigraphy can be used to confirm the presence of transthyretin cardiac amyloidosis in those with high clinical suspicion for cardiac amyloidosis, but without evidence of serum or urine monoclonal light chains.
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