What are the signs of heart failure?

Signs of Heart Failure

The characteristic signs of heart failure include breathlessness (dyspnea), ankle swelling (peripheral edema), and fatigue, which are often accompanied by objective evidence of cardiac dysfunction. 1

Primary Clinical Signs and Symptoms

Cardinal Signs

• Breathlessness (dyspnea) - may occur at rest or during exercise, and can present as nocturnal dyspnea or orthopnea 1
• Peripheral edema - typically manifesting as ankle swelling 1
• Fatigue - a complex symptom related to low cardiac output and peripheral hypoperfusion 1

Additional Clinical Signs

• Raised jugular venous pressure - indicating systemic venous congestion 1
• Hepatomegaly - resulting from right-sided heart failure 1
• Pulmonary rales - indicating pulmonary congestion 1, 2
• Third heart sound - associated with ventricular dysfunction 1, 3
• Displaced cardiac apex - suggesting cardiac enlargement 3
• Tachycardia - compensatory mechanism to maintain cardiac output 1
• Tachypnea - response to reduced oxygen delivery 1
• Pleural effusion - resulting from increased pulmonary venous pressure 1

Pathophysiological Basis of Signs

The origin of heart failure symptoms is complex and not fully understood. Key mechanisms include:

• Increased pulmonary capillary pressure - contributes to pulmonary edema and breathlessness 1
• Low cardiac output - leads to fatigue, peripheral hypoperfusion 1, 4
• Skeletal muscle deconditioning - contributes to exercise intolerance and fatigue 1, 5
• Systemic venous congestion - causes peripheral edema, hepatomegaly, and raised venous pressure 1, 6

Classification of Heart Failure Severity

Heart failure severity is commonly classified using the New York Heart Association (NYHA) functional classification:

• Class I: No limitation of physical activity; ordinary activity doesn't cause symptoms 1
• Class II: Slight limitation; comfortable at rest but ordinary activity causes fatigue, palpitations, or dyspnea 1
• Class III: Marked limitation; comfortable at rest but less than ordinary activity causes symptoms 1
• Class IV: Unable to perform any physical activity without discomfort; symptoms present at rest 1

Diagnostic Considerations

• Clinical signs alone are insufficient for diagnosis - objective evidence of cardiac dysfunction (preferably by echocardiography) is required 1
• Natriuretic peptides (BNP, NT-proBNP) - elevated levels support the diagnosis; normal levels make heart failure unlikely 1
• Chest X-ray - may show cardiomegaly and pulmonary congestion 1
• ECG - abnormalities are common; a normal ECG makes systolic dysfunction unlikely 1

Important Clinical Pitfalls

• There is a poor relationship between symptoms and the severity of cardiac dysfunction 1
• Signs and symptoms may be difficult to interpret in elderly patients, obese individuals, and women 1
• Right and left heart failure present with different predominant signs (systemic vs. pulmonary venous congestion) 1
• Heart failure signs may be masked by optimal diuretic therapy 5
• Symptoms alone cannot guide optimal titration of neurohormonal blockers 1

Differential Considerations

• Other causes of dyspnea (pulmonary disease) should be excluded 1, 3
• Other causes of peripheral edema (venous insufficiency, renal disease) should be considered 6
• High-output states (anemia, thyrotoxicosis, septicemia) can mimic heart failure signs 1