Clinical features and complications
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7229.236 (Published 22 January 2000) Cite this as: BMJ 2000;320:236
- R D S Watson,
- C R Gibbs,
- G Y H Lip
Clinical features
Patients with heart failure present with a variety of symptoms, most of which are non-specific. The common symptoms of congestive heart failure include fatigue, dyspnoea, swollen ankles, and exercise intolerance, or symptoms that relate to the underlying cause. The accuracy of diagnosis by presenting clinical features alone, however, is often inadequate, particularly in women and elderly or obese patients.
Symptoms and signs in heart failure
Symptoms
Dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Reduced exercise tolerance, lethargy, fatigue
Nocturnal cough
Wheeze
Ankle swelling
Anorexia
Signs
Cachexia and muscle wasting
Tachycardia
Pulsus alternans
Elevated jugular venous pressure
Displaced apex beat
Right ventricular heave
Crepitations or wheeze
Third heart sound
Oedema
Hepatomegaly (tender)
Ascites
Symptoms
Dyspnoea
Exertional breathlessness is a frequent presenting symptom in heart failure, although it is a common symptom in the general population, particularly in patients with pulmonary disease. Dyspnoea is therefore moderately sensitive, but poorly specific, for the presence of heart failure. Orthopnoea is a more specific symptom, although it has a low sensitivity and therefore has little predictive value. Paroxysmal nocturnal dyspnoea results from increased left ventricular filling pressures (due to nocturnal fluid redistribution and enhanced renal reabsorption) and therefore has a greater sensitivity and predictive value. Nocturnal ischaemic chest pain may also be a manifestation of heart failure, so left ventricular systolic dysfunction should be excluded in patients with recurrent nocturnal angina.
Common causes of lower limb oedema
Gravitational disorder—for example,immobility
Congestive heart failure
Venous thrombosis or obstruction, varicose veins
Hypoproteinaemia—for example,nephrotic syndrome,liver disease
Lymphatic obstruction
Fatigue and lethargy
Fatigue and lethargy in chronic heart failure are, in part, related to abnormalities in skeletal muscle, with premature muscle lactate release, impaired muscle blood flow, deficient endothelial function, and abnormalities in skeletal muscle structure and function. Reduced cerebral blood flow, when accompanied by abnormal sleep patterns, may occasionally lead to somnolence and confusion in severe chronic heart failure.
Sensitivity, specificity, and predictive value of symptoms, signs, and chest × ray findings for presence of heart failure (ejection fraction <40%) in 1306 patients with coronary artery disease undergoing cardiac catheterisation
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