cardiovascular disorders
Heart Failure (HF)
Symptoms and Signs of Heart Failure
Manifestations of heart failure differ depending on the extent to which the LV and RV are initially affected. Clinical severity varies significantly and is usually classified according to the New York Heart Association (NYHA) system (see table); the examples of ordinary activity may be modified for older, debilitated patients. Because HF has such a broad range of severity, some experts suggest subdividing NYHA class III into IIIA or IIIB. Class IIIB is typically reserved for those patients who recently had a heart failure exacerbation. The American College of Cardiology/American Heart Association has advocated a staging system for HF (A, B, C, or D) to highlight the need for HF prevention. A: High risk of HF but no structural or functional cardiac abnormalities or symptoms B: Structural or functional cardiac abnormalities but no symptoms of HF C: Structural heart disease with symptoms of HF D: Refractory HF requiring advanced therapies (eg, mechanical circulatory support, cardiac transplantation) or palliative care Severe LV failure may cause Pulmonary Edema or the most common symptoms are dyspnea and fatigue due to increased pulmonary venous pressures, and low cardiac output (CO, at rest or inability to augment CO during exertion). Dyspnea usually occurs during exertion and is relieved by rest. As HF worsens, dyspnea can occur during rest and at night, sometimes causing nocturnal cough. Dyspnea occurring immediately or soon after lying flat and relieved promptly by sitting up (orthopnea) is common as heart failure advances. In paroxysmal nocturnal dyspnea (PND), dyspnea awakens patients several hours after they lie down and is relieved only after they sit up for 15 to 20 minutes. In severe HF, periodic cycling of breathing ( Inspection —from a brief period of apnea, patients breathe progressively faster and deeper, then slower and shallower until they become apneic and repeat the cycle)—can occur during the day or night; the sudden hyperpneic phase may awaken the patient from sleep. Cheyne-Stokes breathing differs from PND in that the hyperpneic phase is short, lasting only 10 to 15 seconds, but the cycle recurs regularly, lasting 30 seconds to 2 minutes. PND is associated with pulmonary congestion, and Cheyne-Stokes respiration with low CO. Sleep-related breathing disorders, such as In RV failure,the most common symptoms are ankle swelling and fatigue. Sometimes patients feel a sensation of fullness in the abdomen or neck. Hepatic congestion can cause right upper quadrant abdominal discomfort, and stomach and intestinal congestion can cause early satiety, anorexia, and abdominal bloating. Less specific heart failure symptoms include cool peripheries, postural light-headedness, nocturia, and decreased daytime micturition. Skeletal muscle wasting can occur in severe biventricular failure and may reflect some disuse but also increased catabolism associated with increased cytokine production. Significant weight loss (cardiac cachexia) is an ominous sign associated with high mortality. In older people, presenting complaints may be atypical, such as confusion, delirium, falls, sudden functional decline, nocturnal urinary incontinence, or sleep disturbance. Coexisting cognitive impairment and depression may also influence assessment and therapeutic interventions and may be worsened by the HF. General examination may detect signs of systemic or cardiac disorders that cause or aggravate heart failure (eg, anemia, Hyperthyroidism , alcohol use disorder, In LV failure, tachycardia and tachypnea may occur. Patients with severe LV failure may appear visibly dyspneic or cyanotic, hypotensive, and confused or agitated because of hypoxia and poor cerebral perfusion. Some of these less specific symptoms (eg, confusion) are more common in older patients. Central cyanosis (affecting all of the body, including warm areas such as the tongue and mucous membranes) reflects severe hypoxemia. Peripheral cyanosis of the lips, fingers, and toes reflects low blood flow with increased oxygen extraction. If vigorous massage improves nail bed color, cyanosis may be peripheral; increasing local blood flow does not improve color if cyanosis is central. Cardiac findings in HFrEFinclude Diffuse, sustained, and laterally displaced apical impulse Audible and occasionally palpable 3rd (S3) and 4th (S4) heart sounds Accentuated pulmonic component (P2) of the 2nd heart sound (S2) These abnormal heart sounds also can occur in HFpEF. A pansystolic murmur of mitral regurgitation at the apex may occur in either HFrEF or HFpEF. Pulmonary findingsinclude early inspiratory basilar crackles that do not clear with coughing and, if pleural effusion is present, dullness to percussion and diminished breath sounds at the lung base(s). Signs of RV failureinclude Nontender peripheral pitting edema (digital pressure leaves visible and palpable imprints, sometimes quite deep) in the feet and ankles Enlarged and sometimes pulsatile liver palpable below the right costal margin Abdominal swelling and ascites Visible elevation of the jugular venous pressure, sometimes with largeaorvwaves that are visible even when the patient is seated or standing (see figure) In severe cases of heart failure, peripheral edema can extend to the thighs or even the sacrum, scrotum, lower abdominal wall, and occasionally even higher. Severe edema in multiple areas is termed anasarca. Edema may be asymmetric if patients lie predominantly on one side. Large V waves in the jugular veins are usually indicative of significant tricuspid regurgitation which is often present in RV failure. A paradoxical increase in the jugular venous pressure during inspiration (Kussmaul sign) is indicative of right-sided heart failure and can occur in RV failure, Restrictive Cardiomyopathy , With hepatic congestion, the liver may be palpably enlarged or tender, and hepatojugular or abdominal-jugular reflux may be detected (see Neck veins ). Precordial palpation may detect the left parasternal lift of RV enlargement, and auscultation may detect the murmur of tricuspid regurgitation or the RV S3 along the left sternal border; both findings are augmented upon inspiration. 