Diagnosis

The differential diagnosis includes the following:

Aortic Stenosis

Aortic stenosis is the obstruction of blood flow across the aortic valve. Aortic
stenosis has several etiologies, including congenital (unicuspid or bicuspid valve),
calcific (due to degenerative changes), and rheumatic.

Cardiomyopathy, Alcoholic
Alcohol use has also been shown to have numerous effects on the cardiovascular
system other than heart failure. It has been associated with arrhythmia (eg, atrial
fibrillation, atrial flutter, other supraventricular arrhythmia, premature ventricular
contractions), hypertension, stroke, and sudden death. In addition, the literature
reports alcohol withdrawal being associated with takotsubo, or stress-induced,
cardiomyopathy. On the other hand, numerous studies have demonstrated that light
to moderate alcohol consumption (ie, 1-2 drinks per d or 3-9 drinks per wk)
decreases the risk of cardiac events such as myocardial infarction.

Cardiomyopathy, Cocaine
The fact that subacute, or even chronic, cardiomyopathy may result from the use of cocaine is
being increasingly recognized. While most cases of cocaine-related cardiomyopathy have proved
to be reversible, others have resulted in permanent cardiac dysfunction or death. However,
because morbidity and mortality information associated with cocaine-related cardiomyopathy is
based on case reports, it may be underreported. Many deaths in the drug abuse population are
ascribed to drug toxicity without further attempts at defining the exact etiology.
Complications of cocaine use also include embolic disease (cerebral and in other organs).
Ischemic stroke is seen in the highest frequency in the first few hours after cocaine use, likely
due to a thrombogenic effect associated with platelet activation. However, stroke onset may be
delayed as long as 1 week, possibly due to the formation of longer-acting secondary metabolites.
Cerebral atrophy is also a known feature of chronic cocaine use.
Cardiomyopathy, Dilated
Dilated cardiomyopathy is a progressive disease of heart muscle that is
characterized by ventricular chamber enlargement and contractile dysfunction with
normal left ventricular (LV) wall thickness.

Cardiomyopathy, Hypertrophic
Hypertrophic cardiomyopathy (HCM) is a genetic disorder that is typically inherited
in an autosomal dominant fashion with variable penetrance and variable
expressivity. The disease has complex symptomatology and potentially devastating
consequences for patients and their families.

Cardiomyopathy, Restrictive

The World Health Organization (WHO) defines RCM as a myocardial disease

characterized by restrictive filling and reduced diastolic volume of either or both
ventricles with normal or near-normal systolic function and wall thickness.

Cardiovascular Disease and Pregnancy

Coronary Artery Atherosclerosis

It is the principal cause of coronary artery disease (CAD), in which atherosclerotic

changes are present within the walls of the coronary arteries.

Hypertension

Normal - Systolic lower than 120, diastolic lower than 80

Prehypertension - Systolic 120-139, diastolic 80-90

Stage 1 - Systolic 140-159, diastolic 90-99

Stage 2 - Systolic equal to or more than 160, diastolic equal to or more than 100

Hypertension and Pregnancy

Hypertensive disorders during pregnancy are classified into 4 categories, as recommended by the
National High Blood Pressure Education Program Working Group on High Blood Pressure in
Pregnancy[1] :

Chronic hypertension

Preeclampsia-eclampsia

Preeclampsia superimposed on chronic hypertension

Gestational hypertension (transient hypertension of pregnancy or chronic hypertension

identified in the latter half of pregnancy). This terminology is preferred over the older but
widely used term "pregnancy-induced hypertension" (PIH) because it is more precise.

In 2008, the Society of Obstetricians and Gynecologists of Canada (SOGC) released revised
guidelines that simplified the classification of hypertension in pregnancy into 2 categories,
preexisting or gestational, with the option to add "with preeclampsia" to either category if
additional maternal or fetal symptoms, signs, or test results support this.
Hypertension, Malignant
A hypertensive emergency is a condition in which elevated blood pressure results in
target organ damage. The systems primarily involved include the central nervous
system, the cardiovascular system, and the renal system. Malignant hypertension
and accelerated hypertension are both hypertensive emergencies, with similar

outcomes and therapies. In order to diagnose malignant hypertension, papilledema

(as seen in the image below) must be present.

Mitral Stenosis
Mitral stenosis (MS) is characterized by obstruction to left ventricular inflow at the
level of mitral valve due to structural abnormality of the mitral valve apparatus.

Pulmonary Disease and Pregnancy

Pulmonary Edema, Cardiogenic

Pulmonary edema refers to extravasation of fluid from the pulmonary vasculature

into the interstitium and alveoli of the lung. The formation of pulmonary edema may
be caused by 4 major pathophysiologic mechanisms: (1) imbalance of Starling
forces (ie, increased pulmonary capillary pressure, decreased plasma oncotic
pressure, increased negative interstitial pressure), (2) damage to the alveolarcapillary barrier, (3) lymphatic obstruction, and (4) idiopathic or unknown
mechanism.

Pulmonary Edema, Neurogenic

Neurogenic pulmonary edema (NPE) is a relatively rare form of pulmonary edema
caused by an increase in pulmonary interstitial and alveolar fluid. Neurogenic
pulmonary edema develops within a few hours after a neurologic insult, and
diagnosis requires exclusion of other causes of pulmonary edema (eg, high-altitude
pulmonary edema).

Other problems to be considered include the following:

Arrhythmogenic right ventricular dysplasia

Cardiomyopathy, diabetic heart disease

Infectious, toxic, or metabolic disorders

Noncardiogenic pulmonary edema during pregnancy - Pregnancy is a state of low oncotic

pressure reflected in decreased serum albumin (expected values, ~3.2 mg/dL);
consequently, when other stressors are present, pulmonary edema can occur with normal
cardiac filling pressures; the most common triggers include pyelonephritis and other
infections, corticosteroids, and tocolytics such as beta agonists and magnesium sulfate

Preeclampsia (toxemia of pregnancy)

Current state of knowledge on aetiology, diagnosis,

management, and therapy of peripartum cardiomyopathy:
a position statement from the Heart Failure Association of
the European Society of Cardiology Working Group on
peripartum cardiomyopathy
Table 3

Differential cardiovascular diagnoses of peripartum cardiomyopathy

Distinguishing features

Diagnosis/investigation

PPCM most commonly

presents post-partum,
Pre-existing idiopathic whereas IDC (unmasked by
pregnancy) usually presents
dilated
History, ECG, BNP,
cardiomyopathy (IDC) by the 2nd trimester
echocardiography
unmasked by
IDC usually presents during
pregnancy
pregnancy with larger
cardiac dimensions than
PPCM

Pre-existing familial
dilated
cardiomyopathy
(FDC) unmasked by
pregnancy

HIV/AIDS
cardiomyopathy
Pre-existing valvular
heart disease
unmasked by
pregnancy

PPCM most commonly

presents post-partum,
whereas FDC usually
presents by 2nd trimester
Positive family history in
FDC

History, ECG, BNP,

echocardiography, genetic
testing, family screening

FDC usually presents during

pregnancy with larger
cardiac dimensions than
PPCM
HIV cardiomyopathy
presents often with nondilated ventricles
Rheumatic mitral valve
disease is often unmasked
by pregnancy
PPCM most commonly
presents post-partum

HIV test
History, examination, ECG,
echocardiography

Distinguishing features

Diagnosis/investigation

whereas valvular heart

disease usually presents by
2nd trimester
Hypertensive heart
disease

Pre-existing
unrecognized
congenital heart
disease

Exclude pre-existing severe

hypertension in those
presenting before delivery
Previously unrecognized
congenital heart disease
often has associated
pulmonary hypertension
History, ECG, echocardiography
PPCM most commonly
presents post-partum,
whereas congenital heart
disease usually presents by
2nd trimester

Pregnancy-associated History (but can present

myocardial infarction atypically)

History, ECG, cardiac enzymes,

coronary angiography,
echocardiography

Pulmonary embolus

Medical history, ECG, d-dimers;

consider echocardiography,
ventilation/perfusion scan, CT
pulmonary angiogram

History

ECG, echocardiogram; HIV, human immunodeficiency virus; BNP, B-type natriuretic

peptide.