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Jieun Kim

W. Frank Peacock

Clinical Highlights

The most common ED presentation of patients with dilated cardiomyopathy is decompensated heart failure (HF). Dyspnea is the most common complaint. Other complaints suggesting HF include dyspnea on exertion, orthopnea, peripheral edema, weight gain, paroxysmal nocturnal dyspnea, cough, and fatigue. Because HF may be preceded by myocardial ischemia, risk factors for coronary artery disease should be ascertained. Conditions that worsen or precipitate HF should be considered in the differential diagnosis and include myocardial ischemia, uncontrolled hypertension, arrhythmias, dietary, and medication noncompliance. Physical examination assists in evaluating HF, with vital signs and airway stability being paramount. Pulmonary rales, peripheral edema, jugular venous distention, hepatojugular reflux, and the presence of extra heart sounds identify fluid overload. Skin mottling, indicating poor perfusion, is associated with increased acute mortality.


This photograph shows a patient with jugular venous distension.


This patient also had peripheral edema in the lower extremities demonstrated by the “pitting” that remains after gentle pressure to distal ankle and lateral proximal dorsal foot.

Appropriate testing includes an electrocardiogram (ECG) to evaluate myocardial ischemia, a chest x-ray (CXR) to assess for pulmonary edema, and lab testing for troponin, natriuretic peptide levels, renal function, electrolytes, and hemoglobin.


The ECG demonstrates sinus tachycardia, without diagnostic acute ischemic changes, although there was evidence of left ventricular hypertrophy.


This portable CXR demonstrates cardiomegaly, as determined by the measuring the widest width of the cardiac silhouette and dividing by the widest horizontal width of the chest from right to left pleural surface; a ratio over 0.5 meets criteria for cardiomegaly. The CXR also demonstrates pulmonary vascular congestion represented by the increased diameter of the pulmonary vessels and their hazy contours, including pulmonary vessels in the middle and upper lung fields, especially on the right side for this patient.

The salient differential diagnoses include other conditions manifesting as acute dyspnea (pulmonary embolism, chronic obstructive pulmonary disease exacerbation, or pneumonia), pathology presenting as acute volume overload or edema (eg, renal failure and liver failure), and pump failure resulting from acute myocardial infarction (AMI), acute valve dysfunction, or pericardial disease.

ED Care and Disposition

At initial presentation, the patient’s airway should be evaluated and the need for noninvasive ventilation or endotracheal intubation considered. Hypertensive HF responds remarkably well to vasodilation, which may be performed via sublingual nitroglycerin until intravenous (IV) access is obtained. IV nitroglycerin is well tolerated and large doses may be required ...

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