There is a wide spectrum of potential clinical presentations with heart failure. Most patients have signs and symptoms of pulmonary congestion including dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.
Symptoms
Dyspnoea
Breathlessness or dyspnoea is a cardinal symptom of left ventricular failure and the patient may present with exertional dyspnoea or orthopnoea or paroxysmal nocturnal dyspnoea or acute pulmonary edema.
Exertional Dyspnoea
Degree of physical activity goes on decreasing as the heart failure progresses. Orthopnoea is dyspnoea that develops in recumbent position and is relieved by sitting up. It develops within few minutes of assuming recumbency and occurs when the patient is awake.Decreased pooling of fluid in the lower limbs and shift of fluid to the intrathoracic compartment resulting in increased preload causes orthopnoea.
Paroxysmal Nocturnal Dyspnoea
Here the patient, after going to sleep for sometime, suddenly gets up with dyspnoea and suffocation and sits upright gasping for breath. Bronchospasm may be present and hence is often referred to as cardiac asthma. With patient asleep at night, the increased resorption of fluid into the vascular space, increased intrathoracic volume, elevation of diaphragms due to recumbency,reduced sympathetic support during night and nocturnal depression of respiratory center during night are the factors operative producing paroxysmal nocturnal dyspnoea.
New York Heart Association (NYHA) Classification
It is a useful classification in follow up of patients in heart failure.
Class I – No limitation. Ordinary physical activity does not cause fatigue, dyspnoea or palpitation.
Class II – Slight limitation of physical activity. Ordinary physical activity results in fatigue,dyspnoea or palpitation.
Class III – Marked limitation of physical activity. Less than ordinary activity results in symptoms.
Class IV – Inability to carry out any physical activity without symptoms. Symptoms are present even at rest.
— Fatigue and Weakness: These symptoms are usually related to poor perfusion of the musculature as a result of low cardiac output. These may also occur due to excessive diuresis due to diuretic therapy or due to beta blocker treatment.
— Urinary Symptoms: Nocturia and in later stages oliguria may occur.
— Cerebral Symptoms: These are often seen in older patients who have associated cerebral arteriosclerosis. Confusion, impaired memory, insomnia and disorientation may occur.
— Cough: Cough is due to pulmonary congestion and is a “dyspnoea equivalent” or “orthopnoea equivalent”. It may also be due to use of ACE inhibitors.
— Symptoms of Right-sided Failure: The symptoms are due to systemic venous congestion – pain in right hypochondrium from enlargement of the liver, anorexia, nausea and edema.
— Hemoptysis: This can result from backpressure, rupture of pulmonary venules, respiratory infections and pulmonary embolism.
— Embolism: Embolism can occur to any part of the body like a cerebral embolism. They are most often related to atrial fibrillation or mural thrombi in the ventricle.
Signs
General Examination
The patient will appear anxious and dyspnoeic. Patients in chronic heart failure are usually malnourished and even cachectic. Chronic passive venous congestion may produce exophthalmos. Cyanosis, icterus and edema may be present.
Pulse
There is usually tachycardia associated with coldness of extremities due to adrenergic activity.Irregularly irregular pulse suggests atrial fibrillation, which could have precipitated heart failure.
Jugular Venous Pressure
Elevated jugular venous pressure reflects raised right atrial pressure. V-wave and y descent will be prominent if there is severe tricuspid regurgitation. Jugular venous pressure which is normal at rest gets abnormally elevated when right upper abdominal quadrant is compressed (hepato-jugular reflux)
Liver
The liver is often enlarged and tender. It is pulsatile in the presence of severe tricuspid regurgitation.
Edema
Peripheral, symmetrical, pitting edema, particularly in the dependent parts, noticeable in the ambulant patients towards evening is a cardinal feature of heart failure. In bed-ridden patients, the edema is seen over the sacral area. Long standing edema leads to skin pigmentation.
Pleural Effusion
Pleural veins drain into both systemic and pulmonary veins. When both the venous systems are involved, pleural effusion develops. It is usually bilateral, but when confined to one side, it is generally seen on the right side.
Ascites
Ascites denotes chronic systemic venous hypertension. In tricuspid regurgitation and constrictive pericarditis, ascites may be more prominent than peripheral edema.
Cardiac Findings
Findings related specifically to the underlying cardiac lesions like valvular lesions, shunts or pericardial disease will be present. There are some general findings:
Cardiac Enlargement
This is generally seen in chronic systolic heart failure. In acute heart failure and diastolic heart failure, cardiomegaly is not a feature.
Heart Sounds
Presence of left ventricular third heart sound denotes systolic dysfunction. Fourth heart sound may be present. With tachycardia the extra sounds result in a gallop rhythm either early diastolic or presystolic gallop. With pulmonary hypertension, pulmonary component of the second sound is accentuated. Functional mitral and tricuspid regurgitation murmurs appear with ventricular dilatation.
Pulsus Alternans
It is seen in systolic heart failure and indicates advanced myocardial disease. It tends to disappear with successful treatment of heart failure.
Cheyne Stokes Respiration
This is periodic or cyclical breathing, where periods of apnoea alternates with periods of hyperpnoea during sleep. Left ventricular failure leading to sluggish cerebral circulation is the cause.
Symptoms
Dyspnoea
Breathlessness or dyspnoea is a cardinal symptom of left ventricular failure and the patient may present with exertional dyspnoea or orthopnoea or paroxysmal nocturnal dyspnoea or acute pulmonary edema.
Exertional Dyspnoea
Degree of physical activity goes on decreasing as the heart failure progresses. Orthopnoea is dyspnoea that develops in recumbent position and is relieved by sitting up. It develops within few minutes of assuming recumbency and occurs when the patient is awake.Decreased pooling of fluid in the lower limbs and shift of fluid to the intrathoracic compartment resulting in increased preload causes orthopnoea.
Paroxysmal Nocturnal Dyspnoea
Here the patient, after going to sleep for sometime, suddenly gets up with dyspnoea and suffocation and sits upright gasping for breath. Bronchospasm may be present and hence is often referred to as cardiac asthma. With patient asleep at night, the increased resorption of fluid into the vascular space, increased intrathoracic volume, elevation of diaphragms due to recumbency,reduced sympathetic support during night and nocturnal depression of respiratory center during night are the factors operative producing paroxysmal nocturnal dyspnoea.
New York Heart Association (NYHA) Classification
It is a useful classification in follow up of patients in heart failure.
Class I – No limitation. Ordinary physical activity does not cause fatigue, dyspnoea or palpitation.
Class II – Slight limitation of physical activity. Ordinary physical activity results in fatigue,dyspnoea or palpitation.
Class III – Marked limitation of physical activity. Less than ordinary activity results in symptoms.
Class IV – Inability to carry out any physical activity without symptoms. Symptoms are present even at rest.
— Fatigue and Weakness: These symptoms are usually related to poor perfusion of the musculature as a result of low cardiac output. These may also occur due to excessive diuresis due to diuretic therapy or due to beta blocker treatment.
— Urinary Symptoms: Nocturia and in later stages oliguria may occur.
— Cerebral Symptoms: These are often seen in older patients who have associated cerebral arteriosclerosis. Confusion, impaired memory, insomnia and disorientation may occur.
— Cough: Cough is due to pulmonary congestion and is a “dyspnoea equivalent” or “orthopnoea equivalent”. It may also be due to use of ACE inhibitors.
— Symptoms of Right-sided Failure: The symptoms are due to systemic venous congestion – pain in right hypochondrium from enlargement of the liver, anorexia, nausea and edema.
— Hemoptysis: This can result from backpressure, rupture of pulmonary venules, respiratory infections and pulmonary embolism.
— Embolism: Embolism can occur to any part of the body like a cerebral embolism. They are most often related to atrial fibrillation or mural thrombi in the ventricle.
Signs
General Examination
The patient will appear anxious and dyspnoeic. Patients in chronic heart failure are usually malnourished and even cachectic. Chronic passive venous congestion may produce exophthalmos. Cyanosis, icterus and edema may be present.
Pulse
There is usually tachycardia associated with coldness of extremities due to adrenergic activity.Irregularly irregular pulse suggests atrial fibrillation, which could have precipitated heart failure.
Jugular Venous Pressure
Elevated jugular venous pressure reflects raised right atrial pressure. V-wave and y descent will be prominent if there is severe tricuspid regurgitation. Jugular venous pressure which is normal at rest gets abnormally elevated when right upper abdominal quadrant is compressed (hepato-jugular reflux)
Liver
The liver is often enlarged and tender. It is pulsatile in the presence of severe tricuspid regurgitation.
Edema
Peripheral, symmetrical, pitting edema, particularly in the dependent parts, noticeable in the ambulant patients towards evening is a cardinal feature of heart failure. In bed-ridden patients, the edema is seen over the sacral area. Long standing edema leads to skin pigmentation.
Pleural Effusion
Pleural veins drain into both systemic and pulmonary veins. When both the venous systems are involved, pleural effusion develops. It is usually bilateral, but when confined to one side, it is generally seen on the right side.
Ascites
Ascites denotes chronic systemic venous hypertension. In tricuspid regurgitation and constrictive pericarditis, ascites may be more prominent than peripheral edema.
Cardiac Findings
Findings related specifically to the underlying cardiac lesions like valvular lesions, shunts or pericardial disease will be present. There are some general findings:
Cardiac Enlargement
This is generally seen in chronic systolic heart failure. In acute heart failure and diastolic heart failure, cardiomegaly is not a feature.
Heart Sounds
Presence of left ventricular third heart sound denotes systolic dysfunction. Fourth heart sound may be present. With tachycardia the extra sounds result in a gallop rhythm either early diastolic or presystolic gallop. With pulmonary hypertension, pulmonary component of the second sound is accentuated. Functional mitral and tricuspid regurgitation murmurs appear with ventricular dilatation.
Pulsus Alternans
It is seen in systolic heart failure and indicates advanced myocardial disease. It tends to disappear with successful treatment of heart failure.
Cheyne Stokes Respiration
This is periodic or cyclical breathing, where periods of apnoea alternates with periods of hyperpnoea during sleep. Left ventricular failure leading to sluggish cerebral circulation is the cause.
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