ABC of heart failure: Clinical features and complications

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Abstract
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 View this table: In this window In a new window Sensitivity, specificity, and predictive value of symptoms, signs, and chest x ray findings for presence of heart failure (ejection fraction <40%) in 1306 patients with coronary artery disease undergoing cardiac catheterisation Oedema Swelling of ankles and feet is another common presenting feature, although there are numerous non-cardiac causes of this symptom. Right heart failure may manifest as oedema, right hypochondrial pain (liver distension), abdominal swelling (ascites), loss of appetite, and, rarely, malabsorption (bowel oedema). An increase in weight may be associated with fluid retention, although cardiac cachexia and weight loss are important markers of disease severity in some patients. Physical signs Physical examination has serious limitations as many patients, particularly those with less severe heart failure, have few abnormal signs. In addition, some physical signs are difficult to interpret and, if present, may occasionally be related to causes other than heart failure. Oedema and a tachycardia, for example, are too insensitive to have any useful predictive value, and although pulmonary crepitations may have a high diagnostic specificity they have a low sensitivity and predictive value. Indeed, the commonest cause of lower limb oedema in elderly people is immobility, and pulmonary crepitations may reflect poor ventilation with infection, or pulmonary fibrosis, rather than heart failure. Jugular venous distension has a high specificity in diagnosing heart failure in patients who are known to have cardiac disease, although some patients, even with documented heart failure, do not have an elevated venous pressure. The presence of a displaced apex beat in a patient with a history of myocardial infarction has a high positive predictive value. A third heart sound has a relatively high specificity, although its universal value is limited by a high interobserver variability, with interobserver agreement of less than 50% in non-specialists. Gross oedema of ankles, including bullae with serous exudate In patients with pre-existing chronic heart failure, other clinical features may be evident that point towards precipitating causes of acute heart failure or deteriorating heart failure. Common factors that may be obvious on clinical assessment and are associated with relapses in congestive heart failure include infections, arrhythmias, continued or recurrent myocardial ischaemia, and anaemia. Clinical diagnosis and clinical scoring systems Several epidemiological studies, including the Framingham heart study, have used clinical scoring systems to define heart failure, although the use of these systems is not recommended for routine clinical practice. Precipitating causes of heart failure Arrhythmias, especially atrial fibrillation Infections (especially pneumonia) Acute myocardial infarction Angina pectoris or recurrent myocardial ischaemia Anaemia Alcohol excess Iatrogenic cause—for example, postoperative fluid replacement or administration of steroids or non-steroidal anti-inflammatory drugs Poor drug compliance, especially in antihypertensive treatment Thyroid disorders—for example, thyrotoxicosis Pulmonary embolism Pregnancy In a patient with appropriate symptoms and a number of physical signs, including a displaced apex beat, elevated venous pressure, oedema, and a third...

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