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Acute Pericarditis Differential

The differential diagnosis for acute pericarditis is extensive and includes the following:

1. Idiopathic
2. Infectious
a. Viral (coxsackie virus, echovirus, Epstein-Barr virus, influenza, human immunodeficiency virus, mumps virus)
b. Bacterial (staphylococcus, Haemophilus, pneumococcus, Salmonella, tuberculosis, meningococcus, syphilis)
c. Miscellaneous (histoplasmosis, blastomycosis, coccidioidomycosis, aspergillosis)
3. Rheumatologic (lupus, rheumatoid arthritis, sarcoidosis, dermatomyositis, scleroderma, polyarteritis nodosa, vasculitis, ankylosing spondylitis)
4. Neoplastic (breast, lung, lymphoma, melanoma, leukemia)
5. Primary (sarcomas and mesotheliomas)
6. Drugs (hydralazine, procainamide and others)
7. Immunologic (celiac sprue, inflammatory bowel disease, others)
8. Other causes (uremia, chest trauma, myxedema, aortic dissection, radiation therapy, myocardial infarction, post myocardial infarction syndrome)

Chest Pain Differential:

Although a cardiac ischemic etiology to the chest pain in this patient seems most likely, other potential causes include:

1. Musculoskeletal
2. Pulmonary (pulmonary embolism, pneumothorax)
3. Gastrointestinal (esophageal, acid peptic disease, biliary)
4. Stress and anxiety
5. Other cardiac (valvular disease, pericardial, etc.)

If the results of testing/further evaluation do not confirm a cardiac ischemia, further exploration of the above possibilities may be appropriate.

Contricutive Pericarditis Differential:

The differential diagnosis for constrictive pericarditis includes the following:

1. Idiopathic
2. Postacute pericarditis of any cause
3. Postcardiac surgery
4. Uremia
5. Connective tissue disease (lupus, scleroderma, and rheumatoid arthritis)
6. Post-traumatic
7. Drugs (procainamide, hydralazine, methysergide)
8. Radiation-induced
9. Neoplastic pericardial disease (melanoma, mesothelioma)
10. Infectious: tuberculosis, fungal infections, and parasitic infections
11. Post-myocardial infarction
12. Post-Dressler syndrome
13. Post-purulent pericarditis
14. Pulmonary asbestosis

Dyspnea Differential

The differential diagnosis for dyspnea in this patient includes cardiac causes (ischemia, manifestations of LV dysfunction, valvular disease, pericardial disease, etc.), pulmonary causes (intrinsic lung disease, pneumonia, reactive airway disease, pulmonary embolism, etc.), obesity, deconditioning, and others.

Edema Differential

The differential diagnosis for edema is extensive and includes the following:

1. Increased capillary hydraulic pressure - potentially caused by increased plasma volume and sodium retention (heart failure, renal sodium retention, pregnancy and premenstrual edema, idiopathic edema), venous obstruction (cirrhosis or hepatic venous obstruction, acute pulmonary edema, local venous obstruction) and decreased arteriolar resistance (calcium channel blockers; idiopathic)

2. Hypoalbuminemia - including that caused by protein loss (nephrotic syndrome and protein losing enteropathy) and reduced albumin synthesis (liver disease and malnutrition)

3. Increased capillary permeability - caused by burns, trauma, sepsis, inflammation, allergic reactions, ARDS, diabetes mellitus, interleukin-2 therapy, and malignant ascites.

4. Lymphatic obstruction (post-mastectomy, nodal enlargement due to malignancy, hypothyroidism, malignant ascites)

Narrow QRS Tachycardia Differential

The differential diagnosis for a regular narrow QRS complex tachycardia includes the following:

1. Short RP (RP<PR)

AV nodal reentrant tachycardia
AV reentrant tachycardia
Nonparoxysmal junctional tachycardia

2. Long RP (RP>PR)

Sinus tachycardia
Sinus nodal re-entrance tachycardia
Atrial tachycardia
Permanent junctional reciprocating tachycardia
Nonparoxysmal junctional tachycardia
Unusual type of AV nodal reentry
Atypical AV reentrant tachycardia

Wide QRS Tachycarida Differential

The differential diagnosis of a wide-complex tachycardia includes the following:

1. Ventricular tachycardia
2. Antidromic reciprocating tachycardia
3. Mahaim fibed tachycardia
4. Pacemaker mediated tachycardia
5. Any supraventricular tachycardia with aberrant conduction
6. Any supraventricular tachycardia with bystander accessory pathway activation (except junctional tachycardia)*

*Including atrial fibrillation, atrial flutter, atrial tachycardia, sinus tachycardia, sinus node reentry tachycardia, typical atrioventricular nodal reentry tachycardia, atypical atrioventricular nodal reentry tachycardia, junctional tachycardia, orthodromic reciprocating tachycardia

The diagnosis of ventricular tachycardia as supported by the following features:

1. Evidence of A-V dissociation, fusion beats or capture beats
2. Triphasic configuration (Rsr'or Rr') QRS complex in V1 in the presence of a RBBB morphology
3. QS, QR, or R QRS pattern in V6 in the presence of a RBBB
4. Any Q in V6 in the presence of LBBB
5. A concordant pattern in all precordial leads
6. Brugada Criteria supporting ventricular tachycardia:
-Absence of RS complex in all leads V1-V6
-Interval from beginning of R wave to nadir of S wave >0.1s in any RS lead
-AV dissociation, fusions, or captures seen
-Morphology criteria for VT present both in leads V1 and V6
Monophasic R-wave V1 with notching or slurring in downslope (90%VT) or in upstroke (50:50)
QRS predominantly negative in V6

Pulmonary Hypertension Differential

The differential diagnosis for pulmonary hypertension includes:

1. Hypoxic vasoconstriction: including that caused by COPD, hypoventilatory disorders (sleep apnea, chest wall deformities, living at high altitude)

2. Obliteration of pulmonary vasculature: including pulmonary embolism, collagen vasculature diseases (scleroderma, CREST Syndrome, SLE, and rheumatoid arthritis), vasculitis (Wegner's granulomatosis, polyarteritis nodosa) and miscellaneous disorders (sarcoidosis, lymphangetic spread of carcinoma, pulmonary resection, parasitic or HIV infection, fibrotic reactions [Hamman-Rich syndrome, IV drug abuse, hemaglobinopathies])

3. Volume overload: including shunts (ASD or VSD)

4. Pressure overload: due to atrial hypertension (mitral stenosis or regurgitation; LV systolic or diastolic dysfunction; constrictive pericarditis) or pulmonary venous obstruction (pulmonary venoocclusive disease)

Sinus Tachycardia Differential

The differential diagnosis for sinus tachycardia is fairly extensive and includes fever, volume depletion, hyperthyroidism, anxiety, anemia, pheochromocytoma, sepsis, hypotension and shock, pulmonary embolism, hypoxia, chronic pulmonary disease, heart failure, acute coronary ischemia and infarction, and exposure to stimulants.

Syncope Differential

The differential diagnosis for syncope is broad and includes 1) cardiac causes (tachy or bradyarrhythmia; valvular disease; hypertrophic cardiomyopathy) 2) neurocardiogenic, 3) pulmonary (pulmonary embolism, pulmonary hypertension), 4) neurologic (seizures), and 5) others.

Again, please consider this short collection just a starting point and please feel free to submit differentials for other conditions or expanded differentials for the above. A useful online source of differential diagnoses is http://www.thehealthnews.org/differential_diagnosis/index.html.