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. [...]
[...] The most useful procedure is the transthoracic echocardiogram, which provides a quantitative assessment of left ventricular function and can confirm, in the presence of appropriate symptoms and signs, the presence of heart failure owing to systolic dysfunction or indicate whether the patient has heart failure with preserved systolic function. The echocardiogram also provides a wealth of additional valuable information, including assessment of left and right ventricular size, regional wall motion (as an indicator of prior evaluation of the heart valves, and diagnosis of left ventricular hypertrophy. [...]
[...] Physical Findings The physical findings associated with heart failure generally reflect elevated ventricular filling pressures and, to a lesser extent, reduced cardiac output. In chronic heart failure, many of these findings are absent, often obscuring the correct diagnosis. APPEARANCE AND VITAL SIGNS Compensated patients may be comfortable, but patients with more severe symptoms are often restless, dyspneic, and pale or diaphoretic. Although the heart rate is usually at the high end of the normal range or above beats per minute), it may be lower in chronic, stable patients. [...]
[...] CARDIAC EXAMINATION The cardiac examination is a crucial part of the evaluation of the patient with heart failure, but more for identification of associated cardiac abnormalities than the assessment of its severity. Assessment of the point of maximal impulse may provide information concerning the size of the heart (enlarged if displaced below the fifth intercostal space or lateral to the midclavicular line) and its function (if sustained beyond one third of systole or palpable over two interspaces). Additional precordial pulsations may indicate a left ventricular aneurysm. [...]
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