Cardiac Failure DDx

Overview

In emergency medicine and critical care, the cardiac failure that primarily concerns us is acute heart failure syndrome (AHFS), which refers to rapid worsening of heart failure signs and symptoms, and has many possible causes.

Types of acute heart failure syndrome

AHFS has 5 clinical scenarios which guide acute management:

AHFS 1

• Hypertensive (systolic blood pressure (SBP)>140 mmHg)
• acute pulmonary edema
• little or no systemic edema
• may be hypovolemic or euvolemic

AHFS 2

• Normotensive (SBP 100-140 mmHg)
• gradual onset predominant systemic oedema
• absent or mild pulmonary edema

AHFS 3

• Hypotension (SBP <100 mmHg)
• Signs of organ hypoperfusion predominate
• End-stage cardiac failure or cardiogenic shock (ADD LINK)

AHFS 4

• Evidence of acute coronary syndrome (ADD LINK)
• Symptoms and signs of acute heart failure

AHFS 5

• Isolated right ventricular dysfunction
• acute or gradual onset predominant systemic oedema
• no pulmonary edema

Causes of cardiac failure

Low output failure

• Impaired contractility
  • Ischemia/ infarction
  • Acute mitral or aortic regurgitation
  • myocarditis
  • Cardiomyopathy, e.g. Tako-Tsubo
  • Drugs, e.g. calcium channel blockers
  • Sepsis
  • Infiltrative disorders, e.g. amyolidosis
• Impaired filling
  • Diastolic dysfunction (e.g. hypertensive hypertrophy)
  • Mitral or tricuspid stenosis
  • Restrictive cardiomyopathy
  • Constrictive pericarditis
  • Myxoma
• Excess afterload
  • Aortic or pulmonary stenosis
  • Hypertension
  • Pulmonary hypertension, e.g. pulmonary embolism
• Dysrhythmias

High output failure

• Anemia
• Pregnancy
• Beri beri
• Paget’s disease
• Hyperthyroidism
• Arteriovenous malformations

References and links

• Wiesbauer F. Medical Treatment of Heart Failure. Medmastery

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

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