From the Guidelines
Heart failure presents with a range of clinical symptoms and signs, including dyspnea, fatigue, and fluid retention, which can be identified through a careful history and physical examination, as emphasized in the 2016 ESC guidelines 1. The clinical symptoms and signs of heart failure can vary depending on the severity and type of heart failure, but common symptoms include:
- Shortness of breath (dyspnea), particularly during exertion or when lying flat (orthopnea)
- Paroxysmal nocturnal dyspnea, where patients wake up gasping for air
- Fatigue and weakness due to decreased cardiac output
- Exercise intolerance, limiting daily activities
- Persistent coughing or wheezing, especially when lying down
- Swelling (edema) in the legs, ankles, and feet due to fluid retention On physical examination, clinicians may observe:
- Jugular venous distention
- Pulmonary crackles or rales from fluid in the lungs
- An S3 gallop (third heart sound)
- Hepatomegaly and ascites in advanced cases
- Tachycardia, as the heart attempts to compensate for reduced output These manifestations can be classified according to the New York Heart Association (NYHA) functional classification, ranging from class I (no limitation of physical activity) to class IV (symptoms at rest) 1. It is essential to recognize these signs and symptoms early to ensure timely diagnosis and management of heart failure, as highlighted in the 2016 ESC guidelines 1 and supported by previous guidelines, such as the 2005 ACC/AHA guideline update 1 and the 2014 ACCF and AHA guidelines 1.
From the Research
Clinical Symptoms of Heart Failure
- Dyspnea (shortness of breath) is a prominent symptom in heart failure, related to left atrial pressure 2
- Fatigue is a common symptom, resulting from reduced perfusion of exercising skeletal muscle 3, 4, 2
- Peripheral edema (swelling) is a sign of volume overload, often accompanied by pulmonary rales (crackles) 3, 5
- Breathlessness may be considered the most debilitating symptom in chronic heart failure 4
Signs of Heart Failure
- Elevated jugular venous pressure 5, 6
- Pulmonary crackles (rales) 3, 5
- Peripheral oedema (swelling) 3, 4, 5
- Displaced cardiac apex, a third heart sound, and chest radiography findings of venous congestion or interstitial edema are useful in identifying heart failure 3
Diagnosis and Evaluation
- Echocardiography is the diagnostic standard to confirm systolic or diastolic heart failure through assessment of left ventricular ejection fraction 3, 5
- Natriuretic peptides have a significant negative predictive value for excluding heart failure 5
- The new classification of heart failure distinguishes it by left ventricle ejection fraction (LV EF) into three groups: HFpEF, HFmrEF, and HFrEF 5