Signs and Symptoms of Cardiac Insufficiency (Heart Failure)
The cardinal signs and symptoms of cardiac insufficiency include breathlessness (dyspnea), fatigue, and peripheral edema, which reflect the heart's inability to meet the body's metabolic demands or accommodate venous return. 1
Primary Symptoms
Respiratory Symptoms
- Dyspnea (breathlessness)
- Initially occurs with exertion (NYHA Class II)
- Progresses to occur with minimal activity (NYHA Class III)
- Eventually presents at rest (NYHA Class IV) 1
- Different modes include exertional and nocturnal dyspnea
- Orthopnea (breathlessness when lying flat)
- Paroxysmal nocturnal dyspnea (waking at night with breathlessness)
Fatigue and Weakness
- Essential symptom with complex origins 1
- Caused by:
- Low cardiac output
- Peripheral hypoperfusion
- Skeletal muscle deconditioning 1
- Rapid fatigue with normal activities
Fluid Retention Signs
- Peripheral edema (ankle swelling)
- Raised jugular venous pressure
- Hepatomegaly (liver enlargement)
- Ascites (in advanced cases) 1
Additional Symptoms and Signs
- Palpitations (awareness of irregular heartbeat)
- Cough (may be dry or productive)
- Early satiety and nausea 1
- Dizziness
- Reduced exercise tolerance
- Tachycardia (rapid heart rate)
- Third heart sound (S3 gallop)
- Pulmonary crackles/rales 2
- Weight gain (due to fluid retention)
Severity Classification
The New York Heart Association (NYHA) functional classification is widely used to categorize severity:
| Class | Description |
|---|---|
| I | No limitation: ordinary physical exercise does not cause undue fatigue, dyspnea, or palpitations |
| II | Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations, or dyspnea |
| III | Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms |
| IV | Unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest [1] |
Diagnostic Considerations
- There is a poor relationship between symptoms and the severity of cardiac dysfunction 1
- Symptoms may be difficult to interpret, particularly in elderly patients, the obese, and women 1
- A normal ECG makes heart failure diagnosis unlikely (negative predictive value >90%) 1, 3
- Objective evidence of cardiac dysfunction at rest is necessary for diagnosis, typically via echocardiography 1
- Natriuretic peptides (BNP, NT-proBNP) are helpful in diagnosis, with low levels making heart failure unlikely 1, 3
Clinical Pearls and Pitfalls
- Heart failure symptoms are often non-specific and can mimic other conditions, leading to delayed diagnosis 3
- Symptoms alone cannot guide optimal titration of neurohormonal blockers 1
- Elderly patients may attribute symptoms to aging rather than heart failure 3
- Patients with preserved ejection fraction (HFpEF) may have similar symptoms to those with reduced ejection fraction (HFrEF) 1
- Response to treatment alone is not sufficient for diagnosis but should generally show improvement 3
- The combination of symptoms, signs, and objective evidence of cardiac dysfunction is required for definitive diagnosis 1, 3
Heart failure significantly impairs quality of life across all domains, not just physical functioning, with impacts often more severe than other chronic conditions 4. Early recognition of these signs and symptoms is crucial for timely intervention to improve outcomes and quality of life.