Unexplained Heart Failure And Cardiomegaly Differential Diagnosis And Evaluation

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Symptoms of CHF and associated cardiomegaly or evidence of cardiomegaly in an asymptomatic patient necessitates a directed evaluation. In the vast majority of instances, one of the following five disease entities will eventually be diagnosed. Where appropriate, recognized diagnostic clues are noted.

1. Hypertensive heart disease. Systemic arterial hypertension affects 10 to 20 percent of the adult population. This is a disease with a high prevalence that may be diagnosed at a number of stages. Patients with a dilated cardiomyopathy and untreated cardiac failure frequently present with an elevated blood pressure due to autonomically mediated compensatory reflexes. Isolated involvement of the myocardium as the major manifestation of systemic arterial hypertension is rare. A careful search for evidence of other end-organ damage due to arterial hypertension should be undertaken (examination of fundi, assessment of renal function, evaluation for focal neurologic changes, or history of such entities).

2. Ischemic heart disease (ischemic cardiomyopathy). Most patients with clinical signs of biventricular heart failure and cardiomegaly due to obstructive coronary arterial disease relate a history of typical anginal pain or documented myocardial infarction. A few do not, and clinical presentation and physical findings in these cases mimics those of an idiopathic dilated cardiomyopathy.

3. Valvular heart disease. Although the incidence of rheumatic heart disease in the United States is low, it remains prevalent in underdeveloped countries and is frequently first diagnosed in recent immigrants. The growing geriatric population is prone to calcific aortic stenosis and mitral annular calcification. In addition, bicuspid or unicuspid aortic valve abnormalities remain the most common congenital heart disease. All valvular diseases may present with CHF or incidental cardiac enlargement, and systolic and diastolic murmurs may be noted. Echocardiographic studies are the diagnostic tests of choice in patients with suspected valvular heart disease. Hemodynamic and angiographic studies may be confirmatory.

4. Myocarditis. Patients with severe myocarditis may present with signs and symptoms of cardiac insufficiency. Such patients are usually young, have no significant past cardiac history, have few risk factors for atherosclerotic coronary arterial disease, and present with a recent, abrupt onset of symptoms during or immediately following a systemic or viral illness.

5. Idiopathic cardiomyopathy. This diagnosis should be considered only if the first four entities have been excluded. A careful search for potential causes should then be undertaken.

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