Can a patient with lethargy, New York Heart Association (NYHA) stage 2 classification, diabetes mellitus (DM), hypertension (HPT), dyslipidemia, and coronary heart disease (CHD) be diagnosed with heart failure despite not having classical symptoms?

Can Heart Failure Be Diagnosed Without Classical Symptoms?

Yes, heart failure can and should be diagnosed in this patient despite the absence of classical symptoms like dyspnea or edema, because lethargy alone in a patient with NYHA class II functional limitation and multiple cardiovascular risk factors (diabetes, hypertension, dyslipidemia, coronary heart disease) represents a valid manifestation of the heart failure syndrome. 1

Understanding Heart Failure as a Clinical Syndrome

Heart failure is fundamentally a clinical syndrome characterized by symptoms (dyspnea and fatigue) and signs (edema, rales), but not all patients present with the same symptom profile at the same time 1:

• Some patients have exercise intolerance with little evidence of fluid retention, while others complain primarily of edema with few symptoms of dyspnea or fatigue 1
• The term "heart failure" is preferred over "congestive heart failure" precisely because not all patients have volume overload at initial or subsequent evaluation 1
• Lethargy and fatigue are cardinal manifestations of heart failure that may limit exercise tolerance, even without pulmonary congestion or peripheral edema 1

The Disconnect Between Symptoms and Cardiac Function

A critical pitfall in heart failure diagnosis is assuming that classical symptoms must be present or that symptom severity correlates with cardiac dysfunction:

• There is a poor relation between measures of cardiac performance and the symptoms produced by the disease 1
• Patients with very low ejection fraction may be asymptomatic, whereas patients with preserved LVEF may have severe disability 1
• This apparent discordance may be explained by alterations in ventricular distensibility, valvular regurgitation, pericardial restraint, cardiac rhythm, conduction abnormalities, and right ventricular function 1

NYHA Class II: A Critical Intervention Point

Your patient's NYHA class II status is particularly significant:

• NYHA class II patients have slight limitation of physical activity, are comfortable at rest, but ordinary physical activity results in undue breathlessness, fatigue, or palpitations 1
• Symptom severity correlates poorly with ventricular function, and patients with mild symptoms may still have a relatively high absolute risk of hospitalization and death 1
• NYHA class II represents a critical point on the disease progression continuum when untoward changes can be halted or reversed 2

The High-Risk Profile of Your Patient

The combination of diabetes, hypertension, dyslipidemia, and coronary heart disease creates a particularly high-risk scenario:

• Type 2 diabetes substantially increases the lifetime risk of both developing and dying from heart failure 3
• Diabetes is associated with additional pathophysiologic mechanisms beyond traditional risk factors, including adverse effects on endothelial function, cardiomyocyte ultrastructure, and myocardial metabolism 3
• Even oligosymptomatic patients with heart failure have high risk of death and hospitalization 4

Diagnostic Approach

To confirm heart failure in this patient, you should look for:

Structural or functional cardiac abnormalities 1, 5:

• Reduced left ventricular ejection fraction (LVEF ≤40% for HFrEF, 41-49% for HFmrEF) 1
• Ventricular hypertrophy or chamber enlargement 1, 6
• Wall motion abnormalities 1
• Valvular heart disease 1

Evidence of elevated filling pressures 1, 6:

• Elevated E/e' ratio >9 on echocardiography 6
• Elevated natriuretic peptides (BNP or NT-proBNP) 1, 5
• Invasive hemodynamic measurements if needed 1

Critical Clinical Pearls

Do not dismiss heart failure simply because the patient lacks dyspnea or edema 1. The presence of:

• Lethargy/fatigue as the primary symptom
• NYHA class II functional limitation
• Multiple cardiovascular risk factors
• Coronary heart disease

...creates a compelling clinical picture that warrants full heart failure evaluation and treatment 1, 2.

Even if symptoms are mild or atypical, patients with structural heart disease and any history of symptoms are classified as Stage C heart failure and require guideline-directed medical therapy 1, 7. The staging system is intentionally designed so that patients cannot regress from Stage C back to Stage B once they have developed clinical symptoms 7.