Diagnostic Approach to Chronic Cough with Cardiomegaly and Pulmonary Vascular Congestion

Initial Diagnostic Workup

The European Society of Cardiology recommends transthoracic echocardiography as the essential first-line confirmatory test to verify true cardiomegaly, measure ejection fraction, identify the mechanism of cardiac dysfunction, and assess for structural heart disease 1, 2
The American College of Cardiology suggests that the echocardiogram must evaluate left ventricular systolic function, diastolic function, right ventricular function, valvular structure and function, left atrial size, and estimated pulmonary artery pressures 1, 4
A single transthoracic echocardiography test will differentiate between heart failure with reduced ejection fraction, heart failure with preserved ejection fraction, and non-cardiac causes of the radiographic findings 2
The European Heart Journal recommends obtaining a 12-lead ECG to identify rhythm disturbances, conduction abnormalities, evidence of prior myocardial infarction, left ventricular hypertrophy, or active ischemia 1, 5
A completely normal ECG makes heart failure unlikely and should prompt reconsideration of alternative diagnoses 5
The European Journal of Heart Failure suggests drawing natriuretic peptides which have reasonable negative predictive value for excluding heart failure 1, 5
Low sodium and elevated creatinine are adverse prognostic factors in heart failure 1

Establishing baseline exercise tolerance is critical for gauging heart failure progression, according to the American Heart Association 4
Assessing for orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, and fatigue is essential for diagnosing heart failure, as recommended by the European Society of Cardiology 1
Identifying cardiovascular risk factors including hypertension, coronary artery disease, diabetes, and valvular disease is crucial for determining the underlying cause of heart failure 3
The American College of Cardiology recommends assessing jugular venous pressure for elevated right heart filling pressures 1
Auscultating for a third heart sound indicating elevated left ventricular filling pressure, fourth heart sound, and cardiac murmurs is essential for diagnosing heart failure, according to the European Journal of Heart Failure 1, 4

If echocardiography shows reduced ejection fraction, the American College of Cardiology recommends initiating guideline-directed medical therapy including ACE inhibitors or ARBs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors 3
If echocardiography shows preserved ejection fraction, the European Society of Cardiology suggests focusing on treating underlying conditions such as aggressive blood pressure control for hypertension, rate/rhythm control for atrial fibrillation, and management of volume overload with diuretics 3
If echocardiography shows significant valvular disease, the American Heart Association recommends considering surgical or percutaneous intervention for mitral regurgitation or stenosis 4, 6

Significant left ventricular dysfunction may be present without cardiomegaly on chest X-ray, so normal cardiac silhouette does not exclude heart failure, as noted by the European Journal of Heart Failure 7
Normal chest X-ray findings do not exclude heart failure, especially in early stages, according to the American College of Radiology 7
Chest X-ray has limited diagnostic value when used alone and must be interpreted with clinical findings, echocardiography, and biomarkers, as recommended by the European Society of Cardiology 7
During "flash" pulmonary edema, natriuretic peptide levels may remain normal at initial presentation, according to the European Journal of Heart Failure 1
Chronic cough may be the primary or sole presenting symptom of heart failure, particularly in patients with pulmonary venous congestion, as noted by the European Society of Cardiology 7