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Reliable, easy-to-read patient information on common medical conditions โ€” written in plain language, free of jargon, and grounded in current evidence. Browse the most frequent diagnoses, understand what they mean for everyday life, and learn which steps and questions help you have a focused conversation with your doctor.

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Congestive heart failure differential diagnosis

Introduction

Overview

Overview

Congestive heart failure should be distinguished from other conditions that cause dyspnea, fatigue and edema.

Differentiating Congestive Heart Failure from other Diseases

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 โ‰ฅ 50ย %) 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 โ‰ค 40ย %) 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]_RadioGraphics-2|[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)
 โœ” โœ” โœ” (Low grade) โœ” โœ” (In case of massive PE) โœ” – – – –
Congestive heart failure
  • Goldberg’s criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
    • SV1 or SV2 + RV5 or RV6 โ‰ฅ3.5 mV
    • Total QRS amplitude in each of the limb leads โ‰ค0.8 mV
    • R/S ratio <1 in lead V4
 โœ” โœ” โœ” – – โœ” – – – –
Percarditis
  • ST elevation
  • PR depression
  • Large collection of fluid inside the pericardial sac (pericardial effusion)
  • Calcification of pericardial sac
 โœ” โœ” โœ” (Low grade) โœ” (Relieved by sitting up and leaning forward) – โœ” – – – –
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks – 6 months)
    • Chronic (> 6 months)
Pneumonia โœ” โœ” โœ” โœ” – โœ” โœ” – – –
Vasculitis

Homogeneous, circumferential vessel wall swelling

โœ” โœ” โœ” โœ” โœ” โœ” – โœ” โœ” โœ”
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
 โœ” โœ” – – – โœ” โœ” – – –
COVID-19-associated heart failure โœ” โœ” – – โœ” โœ” – – – – –
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.

References

  1. โ†‘ Brenes-Salazar JA (2014). “Westermark’s and Palla’s signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era”. J Emerg Trauma Shock. 7 (1): 57โ€“8. doi:10.4103/0974-2700.125645. PMCย 3912657. PMIDย 24550636.
  2. _RadioGraphics_2-0|โ†‘ “CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics”.
  3. โ†‘ Bฤ•lohlรกvek J, Dytrych V, Linhart A (2013). “Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism”. Exp Clin Cardiol. 18 (2): 129โ€“38. PMCย 3718593. PMIDย 23940438.
  4. โ†‘ “Pulmonary Embolism: Symptoms – National Library of Medicine – PubMed Health”.
  5. โ†‘ Ramani GV, Uber PA, Mehra MR (2010). “Chronic heart failure: contemporary diagnosis and management”. Mayo Clin. Proc. 85 (2): 180โ€“95. doi:10.4065/mcp.2009.0494. PMCย 2813829. PMIDย 20118395.
  6. โ†‘ Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). “Symptom distress and quality of life in patients with advanced congestive heart failure”. J Pain Symptom Manage. 35 (6): 594โ€“603. doi:10.1016/j.jpainsymman.2007.06.007. PMCย 2662445. PMIDย 18215495.
  7. โ†‘ Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). “Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology”. Eur. J. Heart Fail. 11 (2): 130โ€“9. doi:10.1093/eurjhf/hfn013. PMCย 2639415. PMIDย 19168510.
  8. โ†‘ Takasugi JE, Godwin JD (1998). “Radiology of chronic obstructive pulmonary disease”. Radiol. Clin. North Am. 36 (1): 29โ€“55. PMIDย 9465867.
  9. โ†‘ Wedzicha JA, Donaldson GC (2003). “Exacerbations of chronic obstructive pulmonary disease”. Respir Care. 48 (12): 1204โ€“13, discussion 1213โ€“5. PMIDย 14651761.
  10. โ†‘ Nakawah MO, Hawkins C, Barbandi F (2013). “Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome”. J Am Board Fam Med. 26 (4): 470โ€“7. doi:10.3122/jabfm.2013.04.120256. PMIDย 23833163.
  11. โ†‘ Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). “Pericardial disease: diagnosis and management”. Mayo Clin. Proc. 85 (6): 572โ€“93. doi:10.4065/mcp.2010.0046. PMCย 2878263. PMIDย 20511488.
  12. โ†‘ Bogaert J, Francone M (2013). “Pericardial disease: value of CT and MR imaging”. Radiology. 267 (2): 340โ€“56. doi:10.1148/radiol.13121059. PMIDย 23610095.
  13. โ†‘ Gharib AM, Stern EJ (2001). “Radiology of pneumonia”. Med. Clin. North Am. 85 (6): 1461โ€“91, x. PMIDย 11680112.
  14. โ†‘ Schmidt WA (2013). “Imaging in vasculitis”. Best Pract Res Clin Rheumatol. 27 (1): 107โ€“18. doi:10.1016/j.berh.2013.01.001. PMIDย 23507061.
  15. โ†‘ Suresh E (2006). “Diagnostic approach to patients with suspected vasculitis”. Postgrad Med J. 82 (970): 483โ€“8. doi:10.1136/pgmj.2005.042648. PMCย 2585712. PMIDย 16891436.
  16. โ†‘ Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). “The electrocardiogram in acute pulmonary embolism”. Prog Cardiovasc Dis. 17 (4): 247โ€“57. PMIDย 123074.
  17. โ†‘ Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). “Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease”. COPD. 10 (1): 62โ€“71. doi:10.3109/15412555.2012.727918. PMIDย 23413894.
  18. โ†‘ Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). “Electrocardiogram in pneumonia”. Am. J. Cardiol. 110 (12): 1836โ€“40. doi:10.1016/j.amjcard.2012.08.019. PMIDย 23000104.
  19. โ†‘ Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). “Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis”. Int. J. Cardiol. 199: 170โ€“9. doi:10.1016/j.ijcard.2015.06.087. PMIDย 26209947.
  20. โ†‘ Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). “Cardiac involvement in Churg-Strauss syndrome”. Arthritis Rheum. 62 (2): 627โ€“34. doi:10.1002/art.27263. PMIDย 20112390.

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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]