Congestive heart failure history and symptoms

Resident Survival Guide

Congestive Heart Failure Microchapters
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Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
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Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

The classic symptoms of heart failure include dyspnea, fatigue, and fluid retention. Patients with heart failure present in different ways. Some patients present with exercise intolerance but show little evidence of congestion or edema. Other patients present with mild symptoms of edema and pulmonary congestion. The ejection fraction is usually below 35% in patients who are symptomatic with systolic heart failure.

Symptoms

• Table bellow shows Symptoms and signs of heart failure:

Typical symptoms	More specific signs
Breathlessness Orthopnoea Paroxysmal nocturnal dyspnoea Reduced exercise tolerance Fatigue Tiredness Increased time to recover after exercise Ankle swelling	Elevated jugular venous pressure Hepatojugular reflux Third heart sound (gallop rhythm) Laterally displaced apical impulse
Less typical symptoms	Less specific signs
Nocturnal cough Wheezing Bloated feeling Loss of appetite Confusion (especially in the elderly) Depression Palpitation Dizziness Syncope Bendopnea	Weight gain (>2 kg/week) Weight loss (in advanced HF) Tissue wasting (cachexia) Cardiac murmur Peripheral oedema (ankle, sacral, scrotal) Pulmonary crepitations Pleural effusion Tachycardia Irregular pulse Tachypnoea Cheyne-Stokes respiration Hepatomegaly Ascites Cold extremities Oliguria Narrow pulse pressure

The above table adopted from 2021 ESC Guideline

Symptoms of Left Sided Congestive Heart Failure

The left side pumps blood into the systemic circulation, while the right side pumps blood into the pulmonary circulation. Although left-sided heart failure will reduce forward cardiac output to the systemic circulation, the initial symptoms are often due to pulmonary congestion. In systolic dysfunction, the ejection fraction is decreased, leaving an abnormally elevated volume of blood in the left ventricle. In diastolic dysfunction, left ventricular end-diastolic pressure will be high. This increase in volume or pressure backs up to the left atrium and then into the pulmonary veins. Increased volume or pressure in the pulmonary veins impairs the normal drainage of the alveoli and favors the flow of fluid from the capillaries to the lung parenchyma, causing pulmonary edema. This impairs gas exchange and results in hypoxemia. Thus, left-sided heart failure often presents with respiratory symptoms including:

• Dyspnea
• Frothy sputum
• Nocturnal cough
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Shortness of breath
• Wheezing

New York Heart Association Criteria (NYHA)

The following criteria are often used to gauge the severity of heart failure:

• NYHA I: No symptoms with ordinary activity.

• NYHA II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina.

• NYHA III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

• NYHA IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency present at rest.

Sources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation