Differentials

Ageing/physical inactivity

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SIGNS / SYMPTOMS

Ageing, deconditioning, and/or obesity may cause a reduction in effort tolerance due to dyspnoea and/or fatigue, but without the additional major and minor criteria for diagnosing HF.

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Elucidation of the precise reason for exercise intolerance can be difficult because several disorders may co-exist 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 haemodynamic measurements during graded levels of exercise (i.e., cardiopulmonary exercise test with VO₂ max).

COPD/pulmonary fibrosis

SIGNS / SYMPTOMS
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SIGNS / SYMPTOMS

Dyspnoea may be episodic, with or without environmental triggers, and is usually accompanied by cough, wheezing, sputum, and a history of smoking or industrial exposure.

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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 nanograms/L or 100-400 picograms/mL) in COPD.

Pneumonia

SIGNS / SYMPTOMS
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SIGNS / SYMPTOMS

Patients may present with fever, cough, and productive sputum, with focal signs of consolidation (increased vocal fremitus and bronchial breathing).

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CXR may show signs of consolidation. FBC may show elevated WBC, and blood cultures may be positive for the aetiological organism.

Pulmonary embolism (PE)

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SIGNS / SYMPTOMS

Sudden onset of chest pain, dyspnoea, and haemoptysis, especially after childbirth, are suggestive of PE.[117] Dyspnoea with or without chest pain may be present in other conditions associated with venous thrombosis and PE (e.g., cancer, prolonged immobilisation, postoperative state).

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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.

Post-partum cardiomyopathy (PPCM)

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SIGNS / SYMPTOMS

Patients most commonly present with dyspnoea, but other frequent complaints include cough, orthopnoea, paroxysmal nocturnal dyspnoea, haemoptysis, and chest discomfort, which are also common symptoms of pulmonary embolism.[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 recognisable 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 pre-eclampsia/eclampsia/post-partum hypertension, and maternal cocaine misuse.

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In the presence of raised 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
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SIGNS / SYMPTOMS

Typically causes jaundice, fatigue, nausea, peripheral oedema, ascites, bruising and prolonged bleeding, gynaecomastia, and haematemesis.

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

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SIGNS / SYMPTOMS

Typically causes peripheral oedema, fatigue, dyspnoea, and loss of appetite.

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Urinalysis shows proteinuria, and serum albumin is reduced. Twenty-four-hour urine collection shows >3.5 g protein. Serum urea and creatinine clearance may be abnormal in later stages. Serum cholesterol and triglyceride levels may be raised. Kidney ultrasound and biopsy may reveal the underlying cause.

Pericardial disease

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SIGNS / SYMPTOMS

May present with chest pain, typically worse on lying down, swallowing or coughing; tachycardia; dyspnoea; cough; oedema; 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

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SIGNS / SYMPTOMS

Oedema 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

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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

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SIGNS / SYMPTOMS

No differentiating signs or symptoms. Patient may have an underlying condition (e.g., multiple myeloma).

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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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