Evaluation of a Patient with Possible Heart Failure

The common symptoms of heart failure are well known but are frequently absent and variably specific for this condition. The symptoms generally reflect, but may be dissociated from, the hemodynamic derangements of elevated left-sided and right-sided pressures and impaired cardiac output or cardiac output reserve. Dyspnea, or perceived shortness of breath, is the most common symptom of patients with heart failure. In most patients, dyspnea is present only with activity or exertion. The underlying mechanisms are multifactorial. The most important is pulmonary congestion with increased interstitial or intra-alveolar fluid, which activates juxtacapillary J receptors, which stimulate a rapid and shallow pattern of breathing. Increased lung stiffness may enhance the work of breathing, leading to a perception of dyspnea.

[...] Heart failure is associated with additional abnormalities of skeletal muscle itself, including biochemical changes and alterations in fiber types, which increase muscle fatigue and impair muscle function. Finally, heart failure may affect adversely respiratory muscle function and ventilatory control. FATIGUE Fatigue is a common, if nonspecific, complaint of patients with heart failure. Perhaps the most common origin of this complaint is muscle fatigue. Fatigue also may be a nonspecific response to the systemic manifestations of heart failure, such as chronic increases in catecholamines and circulating levels of cytokines, sleep disorders, and anxiety. [...]

[...] Ascites is unusual in heart failure and almost always is associated with peripheral edema. Most commonly, there is severe tricuspid regurgitation, with potential damage to the liver. Otherwise, significant primary liver disease should be suspected as an exacerbating factor or cause of ascites. Pleural effusions are fairly common in chronic heart failure, especially when they are accompanied by left-sided and right-sided manifestations. The effusions result from an increase in transudation of fluid into the pleural space and impaired lymphatic drainage owing to elevated systemic venous pressures. [...]

[...] Dyspnea is a relatively sensitive symptom of heart failure, provided that a careful history is taken of the patient's level of activity, but dyspnea may become less prominent with the onset of right ventricular failure and tricuspid regurgitation, which may lead to lower pulmonary venous pressures. Dyspnea is a common symptom of patients with pulmonary disease, obesity, and anemia and of sedentary individuals. ORTHOPNEA AND PAROXYSMAL NOCTURNAL DYSPNEA Orthopnea is dyspnea that is positional, occurring in the recumbent or semirecumbent position. [...]