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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Acute onset of profound dyspnea and orthopnea

  • Jugular venous distention, diffuse pulmonary rales, and tachycardia

  • Left ventricular (LV) systolic or diastolic dysfunction

GENERAL CONSIDERATIONS

  • Clinical syndrome characterized by sudden development of respiratory distress and interstitial pulmonary edema

  • Primary pathogenic mechanism is an elevation in pulmonary capillary pressure due to LV systolic or diastolic dysfunction

  • Compensatory mechanisms result in neurohumoral activation, tachycardia, and elevated systemic vascular resistance that further increase LV filling pressures and worsen pulmonary edema

  • Can occur in the absence of heart disease with fluid overload due to blood transfusion or severe renal disease

  • Results in reduced diffusion capacity and lung compliance, hypoxia, and dyspnea

  • Rate of increase in pulmonary edema related to pulmonary venous pressure and capacity of the lymphatic vessels to remove excess fluid

  • Causes of acute pulmonary edema:

    • – Myocardial ischemia

    • – Acute aortic insufficiency

    • – Acute mitral regurgitation

    • – Mitral stenosis

    • – Renal vascular hypertension

    • – Other conditions in the presence of preexisting diastolic dysfunction (eg, fever, sepsis, anemia, thyroid disease, cardiac dysrhythmia)

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Acute onset or worsening of cough and dyspnea

  • Chest discomfort

  • Diaphoresis

PHYSICAL EXAM FINDINGS

  • Tachypnea and use of accessory respiratory muscles

  • Tachycardia

  • Jugular venous pressure may be elevated

  • Diffuse pulmonary rales

  • Hypertension or hypotension

  • New or changed murmur

  • S3 or S4

  • Peripheral edema may be present

DIFFERENTIAL DIAGNOSIS

  • Pulmonary emboli

  • Bilateral pneumonia

  • Acute respiratory distress syndrome

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Arterial blood gases: can quantify the level of hypoxia

  • CBC: may suggest infection or identify anemia as precipitating events

  • Electrolyte, blood urea nitrogen, and creatinine: may identify renal dysfunction

  • Cardiac enzymes (eg, troponin): may be elevated in the presence of myocardial ischemia

  • Thyroid function tests

ELECTROCARDIOGRAPHY

  • Sinus tachycardia

  • Left atrial enlargement

  • Atrial fibrillation or flutter with a rapid ventricular response

  • ST- and T-wave changes suggestive of myocardial ischemia

  • LV hypertrophy

IMAGING STUDIES

  • Chest x-ray:

    • – Variable pulmonary vascular redistribution and interstitial edema

    • – Perihilar alveolar edema (“butterfly” appearance)

    • – Cardiac silhouette may be normal or enlarged

    • – Pleural effusions may or may not be present

  • Transthoracic echocardiography:

    • – To assess the degree of LV systolic and/or diastolic dysfunction

    • – To identify the presence of valvular disease

    • – To estimate the pulmonary artery systolic pressure and right atrial pressure

    • – New wall motion abnormalities may suggest myocardial ischemia or injury

DIAGNOSTIC PROCEDURES

  • Right heart catheterization: often not necessary but typically reveals the following:

    • – Marked elevations in pulmonary capillary wedge pressure

    • – Pulmonary artery pressure and sometimes right atrial pressure

    • – Cardiac output may be reduced ...

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