Primary Cardiac Causes

Coronary artery disease is the most common cardiac cause of dyspnea and occurs when myocardial oxygen supply does not meet demand 1
Nonischemic cardiomyopathies include dilated, hypertrophic, and restrictive forms that can cause dyspnea through impaired systolic or diastolic function 1, 2
Mitral valve disease (stenosis or regurgitation) can cause dyspnea through elevated left atrial pressures and pulmonary congestion 1, 2, 3
Aortic stenosis may be present even in younger patients with congenital bicuspid aortic valve 1, 2
Aortic insufficiency can lead to volume overload and eventual left ventricular dysfunction 1, 2
Atrial fibrillation can cause dyspnea through rapid ventricular response, loss of atrial kick, or tachycardia-induced cardiomyopathy 1, 2, 3
Inappropriate sinus tachycardia and other tachyarrhythmias may present primarily with dyspnea 1, 2
Bradyarrhythmias including sick sinus syndrome can reduce cardiac output and cause exertional dyspnea 1, 2
Constrictive pericarditis restricts ventricular filling and causes elevated filling pressures 1, 2, 3
Pericardial effusion with tamponade can present with dyspnea, though typically with additional signs of hemodynamic compromise 1, 2

Diagnostic Approach

Clinical tools including history, physical examination, chest radiography, and electrocardiography have high specificity (96%) but low sensitivity (59%) for cardiac causes 1, 2
Echocardiography should be performed in all patients with dyspnea of suspected cardiac origin to assess cardiac structure, function, valvular disease, and filling pressures 1, 2, 3
Chest radiography can identify cardiomegaly, pulmonary congestion, and pleural effusions suggestive of heart failure 1, 2
Electrocardiography may reveal ischemic changes, arrhythmias, or chamber enlargement 1, 2
B-type natriuretic peptide (BNP) or NT-proBNP measurement helps exclude heart failure when normal (BNP <100 pg/mL or NT-proBNP <125 pg/mL) 4
Stress echocardiography is uniquely positioned to characterize cardiovascular causes of dyspnea including ischemia-induced systolic dysfunction 1, 2
Coronary CT angiography (CCTA) has emerged as a noninvasive alternative to catheter angiography for assessing coronary artery disease 1, 2, 3
Cardiac MRI can evaluate for cardiomyopathies, myocarditis, and infiltrative diseases when echocardiography is inconclusive 1, 3
Invasive coronary angiography remains the gold standard for coronary artery assessment when revascularization is being considered 1, 2

Normal chest radiography does not exclude cardiac disease, particularly early heart failure or diastolic dysfunction 1, 2

The American College of Radiology recommends that dyspnea from CHF and CAD be differentiated based on whether the dyspnea results from ischemia-induced myocardial dysfunction or non-ischemic heart failure, as CAD is the most common cause of CHF 5, 6
Patients with exertional limitation, characterized by a gradual decline in exercise tolerance over weeks to months, may be experiencing dyspnea related to CHF, according to the American College of Cardiology 7
The American College of Radiology suggests that chest X-ray findings, including cardiomegaly, upper lung zone flow redistribution, interstitial or alveolar edema, and bilateral pleural effusions, can indicate CHF-related dyspnea 8

The American College of Radiology recommends that echocardiography be performed in all patients with dyspnea of suspected cardiac origin to assess left ventricular ejection fraction (LVEF), wall motion abnormalities, and valvular function 5, 9
Cardiac MRI with late gadolinium enhancement (LGE) has a diagnostic sensitivity of 67-100% and specificity of 96-100% for detecting ischemic myocardial damage, according to the American College of Radiology 10
Stress echocardiography can identify both resting and post-stress wall motion abnormalities that correlate with clinical outcomes and suggest ischemic etiology, as recommended by the American College of Radiology 10, 6

Patients with a history of MI, hypertension, or diabetes warrant evaluation for CAD as the underlying cause of heart failure, as CAD remains the major source of heart failure with reduced ejection fraction, according to the American College of Radiology 10, 6
The American College of Radiology suggests that coronary CT angiography has limited utility in high-risk patients due to low specificity from heavy calcification, small vessels, and stent artifacts, and recommends proceeding directly to invasive angiography when revascularization is being considered 5, 9, 8