What are the symptoms of chronic heart failure in an adult patient with a history of cardiovascular disease?

Symptoms of Chronic Heart Failure

Heart failure is defined by two cardinal symptom categories: dyspnea and fatigue (which limit exercise tolerance), and fluid retention (which causes pulmonary congestion and peripheral edema). 1

Primary Symptoms

Dyspnea (Shortness of Breath)

• Exertional dyspnea is the most common presenting symptom, occurring with physical activity and progressively worsening as the disease advances 1
• Orthopnea (shortness of breath when lying flat) develops as left-sided filling pressures increase, forcing patients to sleep with elevated head position 2
• Paroxysmal nocturnal dyspnea (sudden awakening with breathlessness) occurs in more advanced disease 1
• Dyspnea at rest indicates severe, advanced heart failure (NYHA Class IV) 1

Fatigue and Exercise Intolerance

• Profound fatigue and reduced exercise tolerance are cardinal manifestations that may dominate the clinical picture even when fluid retention is minimal 1
• Patients experience progressive limitation in activities of daily living, though this decline may be so gradual that patients fail to recognize it unless specifically questioned 1
• The severity of fatigue does not correlate with ejection fraction—patients with very low ejection fractions may be asymptomatic while those with preserved systolic function may have severe disability 1, 3

Signs of Fluid Retention

Peripheral Edema

• Leg swelling (bilateral lower extremity edema) is a common presenting complaint, though it may occur without dyspnea in some patients 1
• Edema can extend to the abdomen, presacral area, and scrotum in severe cases 1
• Ascites develops with advanced right-sided congestion 1

Pulmonary Congestion

• Pulmonary rales are often absent in chronic heart failure despite markedly elevated left-sided filling pressures, because rales reflect the rapidity of onset rather than the degree of volume overload 1
• Pleural effusions may develop with chronic congestion 4

Critical Clinical Pattern

The two symptom categories (dyspnea/fatigue versus fluid retention) do not necessarily dominate the clinical picture simultaneously—some patients have severe exercise intolerance with minimal edema, while others complain primarily of edema with few dyspnea or fatigue symptoms 1

Signs on Physical Examination

Volume Overload Assessment

• Jugular venous distention is the most reliable sign of volume overload, either at rest or with abdominal compression (hepatojugular reflux) 1
• Right-sided filling pressures are elevated in most patients with chronically elevated left-sided filling pressures 1
• Hepatomegaly indicates systemic venous congestion 1

Hypoperfusion Signs (Advanced Disease)

• Narrow pulse pressure suggests severely reduced cardiac output 1
• Cool extremities indicate peripheral vasoconstriction 1
• Altered mentation reflects cerebral hypoperfusion 1
• Cheyne-Stokes respiration (periodic breathing pattern) occurs with advanced failure 1
• Resting tachycardia compensates for reduced stroke volume 1

Constitutional Symptoms

• Nausea and lack of appetite are common constitutional symptoms 5
• Cardiac cachexia (loss of skeletal muscle mass and body fat) develops as heart failure progresses 1, 5

Important Clinical Pitfalls

Heart failure is a clinical diagnosis based on history and physical examination—there is no single diagnostic test 1. The diagnosis requires both symptoms AND objective evidence of cardiac structural or functional abnormality 4.

Do not diagnose heart failure based solely on symptoms (dyspnea, fatigue, edema) without objective cardiac evidence, as these symptoms have numerous noncardiac causes 6, 4.

Many patients with chronic heart failure have elevated intravascular volume without peripheral edema or rales—studies show plasma volume expansion in more than 50% of patients where clinical volume overload was not recognized 1.