What subjective questions should be asked to a patient with reduced ejection fraction (REF) heart failure to assess their symptoms and functional status?

Subjective Questions to Ask Patients with Reduced Ejection Fraction Heart Failure

Ask patients with HFrEF about dyspnea patterns (at rest, on exertion, orthopnea, paroxysmal nocturnal dyspnea), weight changes, swelling, fatigue, functional capacity for daily activities, and substance use history including alcohol, tobacco, illicit drugs, and dietary sodium intake at every visit. 1

Core Symptom Assessment

Dyspnea Evaluation

• Dyspnea at rest: Ask if the patient experiences frequent uncomfortable awareness of breathing while sitting still 1
• Dyspnea on exertion: Determine the specific level of activity that triggers breathlessness:
  • Can they run or play sports?
  • What distance can they walk on flat ground before stopping?
  • What distance can they walk uphill before stopping?
  • Do they need to rest while dressing?
  • How long can they stand before becoming short of breath? 1
• Orthopnea: Ask if they experience uncomfortable breathing when lying flat, how many pillows they use to sleep comfortably, whether they sleep in a chair or recliner, or if they have a recurrent cough when lying down 1
• Paroxysmal nocturnal dyspnea: Ask if they suddenly wake from sleep gasping for air or with distress that improves when sitting up (any episode lasting >5 minutes is significant) 1

Volume Status and Congestion

• Weight changes: Ask about pounds or kilograms gained or lost and the timeframe over which this occurred 1
• Swelling: Ask about puffiness or swelling in the legs, ankles, abdomen, or other body areas, including when it started and how long it has lasted 1

Functional Capacity and Quality of Life

• Activities of daily living: Assess their ability to perform routine tasks like bathing, dressing, cooking, shopping, and housework 1
• Desired activities: Ask what activities they want to do but cannot due to their symptoms 1
• Fatigue: Ask if they experience unusual tiredness or inability to perform their usual activities, including onset and duration 1

Substance Use and Lifestyle History

Critical Exposures

• Alcohol consumption: Quantify current and past use (alcohol-induced cardiomyopathy is reversible) 1, 2
• Tobacco use: Document current smoking status and pack-year history 1
• Illicit drug use: Specifically ask about cocaine, methamphetamines, and other cardiotoxic substances 1, 2
• Chemotherapy exposure: Ask about any history of cancer treatment with cardiotoxic agents 1, 2
• Alternative therapies: Document use of herbal supplements or non-prescription treatments 1
• Dietary sodium intake: Assess typical daily salt consumption and food preparation habits 1

Medication and Treatment Adherence

Current Medication Use

• Diuretic response: Ask if they are taking water pills and whether they notice increased urination 1
• Medication side effects: Inquire about dizziness, lightheadedness, cough, or other symptoms that might indicate medication intolerance 1
• Adherence barriers: Ask about difficulty affording medications, confusion about dosing, or reasons for missing doses 1

Comorbidity Assessment

Associated Conditions

• Chest pain or anginal symptoms: Ask about pressure, tightness, or discomfort with exertion (suggests coronary artery disease as etiology) 1, 2
• Palpitations or irregular heartbeat: Document frequency and associated symptoms 1
• Sleep disturbances: Ask about snoring, witnessed apneas, or daytime sleepiness (screen for sleep-disordered breathing) 1
• Depression symptoms: Inquire about mood, interest in activities, and whether they are taking antidepressants 1
• Cognitive changes: Ask about memory problems, confusion, or difficulty concentrating 1

Red Flag Symptoms Requiring Urgent Assessment

High-Risk Features

• Worsening symptoms despite therapy: Ask if symptoms are getting worse even with medication adjustments 1
• Recurrent hospitalizations: Document emergency department visits or admissions in the past 12 months 1
• Syncope or near-syncope: Ask about fainting spells or feeling like they might pass out 1
• ICD shocks: If they have a defibrillator, ask about any shocks received 1
• Inability to lie flat: Severe orthopnea requiring upright positioning at all times indicates advanced disease 1

Functional Classification Context

Document New York Heart Association (NYHA) functional class by asking: Can they perform ordinary physical activity without symptoms (Class I), do ordinary activities cause symptoms (Class II), are they comfortable at rest but less-than-ordinary activity causes symptoms (Class III), or are they symptomatic at rest (Class IV)? 1

Common Pitfalls to Avoid

• Do not assume dyspnea is solely from heart failure: Patients may have coexisting pulmonary disease, deconditioning, obesity, or anemia contributing to breathlessness 1
• Do not overlook gradual functional decline: Patients may not recognize their progressive limitation if it occurs slowly—specifically ask about changes compared to 6-12 months ago 1
• Do not miss reversible causes: Always ask about recent viral illnesses (myocarditis), pregnancy history (peripartum cardiomyopathy), and thyroid symptoms 2
• Do not forget to assess quality of life beyond heart failure: Many patients rate non-cardiac medical problems or social factors as equally or more limiting than their heart failure 3