Heart%20failure%20-%20chronic Signs and Symptoms

Heart Failure (HF)

• Clinical syndrome due to a structural or functional cardiac abnormality that impairs the ability of the ventricle to fill with or eject blood in order to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues in spite of normal filling pressures or only at the expense of elevated filling pressures
  • Corroborated by objective evidence of cardiogenic, pulmonary or systemic congestion or elevated levels of natriuretic peptides
• Symptoms are caused by ventricular dysfunction secondary to abnormalities of the myocardium, pericardium, endocardium, valves, heart rhythm or conduction

Common Causes of Heart Failure

• Cardiac pathologies (eg coronary artery disease [CAD], cardiomyopathies, congenital heart disease, tachyarrhythmia, valvular heart disease)
• Hypertension
• Infiltrative cardiac diseases (eg amyloid, hemochromatosis, sarcoid)
• Infections (eg rheumatic fever, sexually transmitted diseases, pneumonia)
• Endocrine disorders (eg diabetes, dyslipidemia, hypo/hyperthyroidism, adrenal disorder, pheochromocytoma)
• Nutritional disorders (eg deficiency of thiamine, selenium, iron, calcium, phosphates and L-carnitine, obesity, cachexia)
• Toxins (eg alcohol, medications, trace elements, illicit drug use eg cocaine, cannabis, methamphetamine)
• Drugs (eg beta-blockers, calcium antagonists, antiarrhythmics, cardiotoxic chemotherapy agents, nonsteroidal anti-inflammatory drugs [NSAIDs], non-compliance to medications)
• Other diseases (eg inflammatory/immunological diseases, neuromuscular disease, malignancies, severe anemia, renal dysfunction, renal artery stenosis and end-stage renal failure)

• Incidence of HF increases with age with higher increase in females compared to males
• Prevalence rate in adults is 1-2% or approximately 64 million, with prevalence increasing with age
  • Prevalence rate in patients <55 years old is approximately 1% and >10% in patients ≥70 years old
• Prevalence rates are higher in North Africa, Central Europe, and Middle East and lowest in Eastern Europe and Southeast Asia
• Lifetime risk of developing HF is approximately 20% in individuals >40 years of age

• HF results from impairment of cardiac contractile function (systolic dysfunction) and cardiac filling impairment (diastolic dysfunction)
• Cardiac injury stimulates cellular, structural and neurohumoral modulations influencing cell function leading to activation of the sympathoadrenergic and renin-angiotensin-aldosterone system (RAAS) and resulting to adaptive mechanisms accompanied by volume overload, tachycardia, dyspnea and further deterioration of the cellular function
  • Catecholamines increase intracellular calcium thereby increasing contractility but increases myocardial oxygen demand in the long run which can lead to life-threatening arrhythmias and activation of signaling pathways of hypertrophy and cell death resulting to further cardiac function deterioration
  • Permanent activation of the neurohumoral system also affects cell expression and cell function (eg stretch-induced force generation, frequency-induced force generation, interstitial and structural cell-interaction)

Heart Failure with Preserved Ejection Fraction (HFpEF)

• Characterized by impaired ventricular relaxation and/or filling, increased ventricular stiffness and elevated filling pressure accompanied by pressure overload
• Structural and cellular changes (eg alteration of cardiomyocyte relaxation and inflammation, cardiomyocyte hypertrophy, intercellular fibrosis) causes the inability of the left ventricle (LV) to relax properly
  • Impairment of myocardial relaxation leads to reduced rate and amount of early diastolic LV filling resulting to shifting of LV filling to late diastole with atrial contraction making an important contribution to LV filling
• Alteration of LV diastolic function leads to decreased LV chamber distensibility and increased diastolic pressure at any given LV volume
• Associated with structural remodeling affecting LV and left atrium, right ventricle, cardiomyocytes and extracellular matrix

Heart Failure with Reduced Ejection Fraction (HFrEF)

• Substantial acute or chronic cardiomyocyte loss after myocardial infarction, genetic mutation, myocarditis or valvular disease with cell death due to overload leads to systolic dysfunction development
  • Major structural change is eccentric remodeling accompanied by chamber dilatation and volume overload resulting to forward failure
    • Volume overload results from permanent neurohumoral activation
• Systolic dysfunction triggers neurohumoral activation and cardiac remodelling causing increased sympathetic activity which restores cardiac output by increasing contractility and heart rate
  • Reduced cardiac output also stimulates salt and water retention causing blood volume expansion leading to increased end-diastolic pressure and volume

Signs

More Specific Signs

• S3 gallop
• Laterally displaced or prominent apical impulse
• Elevated jugular venous pressure (JVP)
• Hepatojugular reflux

Less Specific Signs

• Irregular pulse
• Tachycardia with pulsus alternans
• Narrow pulse pressure
• Murmurs/S4 gallop
• Pulmonary rales or crepitations
• Reduced air entry or dullness at lung bases
• Tachypnea/orthopnea
• Weight gain (>2 kg/week)
• Weight loss (in advanced HF)
• Oliguria
• Other findings (eg hepatomegaly, ascites, peripheral edema/bilateral ankle edema, cold extremities, cachexia)

Symptoms

• Many symptoms of HF are nonspecific and do not distinguish between HF and other diseases

More Specific Symptoms

• Dyspnea at rest or on exertion/breathlessness
• Paroxysmal nocturnal dyspnea
• Orthopnea
• Reduced exercise capacity
• Fatigue/longer time to recover post exercise
• Edema/ankle swelling

Less Specific Symptoms

• Nocturnal cough
• Wheezing
• Palpitations
• Dizziness
• Bendopnea
• Bloated feeling
• Anorexia
• Confusion (especially in the elderly)
• Depression
• Syncope

Presentation of Patients with Heart Failure

Decreased Exercise Tolerance

• Dyspnea and/or fatigue occurring at rest or during exercise
• Impaired exercise tolerance not noticed by patient as it occurs gradually

Fluid Retention

• Complaints of leg or abdominal swelling as primary symptom

No Symptom or Symptoms of Another Cardiac or Other Disease

• Cardiac enlargement or dysfunction may be noted during their evaluation for a disease other than HF