Heart failure (HF) is a complex disease that is defined by a failure to meet the systematic demands of circulation. While patients generally present with varying HF symptoms based on the distinct classification of their HF, the most common signs and symptoms are shortness of breath (dyspnea), fatigue and lethargy, lower extremity edema, and chest pain and discomfort.1,2 Later stages of HF may also have tachycardia, increased jugular venous pressure, pulmonary edema, and abnormal lung sounds.3
Dyspnea and orthopnea
Dyspnea is defined as the “uncomfortable awareness of breathing that demands increased effort.” Dyspnea is one of the most common symptoms of HF and is consistently reported in more than half of HF patients.3 A study of patients hospitalized for acute decompensated heart failure (HF) with preserved systolic function (PSF) found that of 45,607 participants 35% had dyspnea at rest.4 A study was conducted to evaluate signs and symptoms in the 3 months prior to hospitalization and mortality among newly diagnosed HF patients. The most common symptom occurring in the 3 months prior to hospitalization was shortness of breath (SOB) (22.0%). Prior to a heart failure admission, shortness of breath was the most common symptom, reported in 36.8% of cases versus 16.6% of controls.5
In addition, dyspnea among HF patients should be closely monitored as it is often linked to the functional capacity and exercise tolerance of the patient. According to the 2022 American Heart Association Guidelines for HF management, shortness of breath can reduce exercise capacity.3 As patients progress through HF stages I to IV, their dyspnea may further worsen with less physical exertion.
Orthopnea is defined as a sensation of breathlessness that occurs when a patient is lying flat and is relieved by assuming an upright position (sitting or standing).3
Fatigue and Lethargy
Studies quantifying the prevalence of symptoms among patient with HF have found that between 53% to 85% of HF patients report experiencing frequent fatigue or lethargy.6,7 For HF patients, fatigue is often described as physical weakness and lethargy, and is mainly due to HF-induced circulation-related abnormalities in skeletal muscles.8 HF patients often have abnormal skeletal muscle structure at baseline and, as the disease progresses, may further lose muscle bulk and strength.
A study was conducted to look at how fatigue evolves over time in patients with chronic heart failure and whether fatigue patterns are linked to mortality risk. Compared to the 19% death rate in the reference group, those with minimal exertion fatigue experienced just a 3% mortality rate (hazard ratio (HR) 0.12; 95% CI [0.02–0.93]; p=0.04), whereas patients in the severe exertion‐fatigue category had a mortality rate of 29% (HR 2.59; 95% CI [1.09–6.16]; p=0.03).9
In another retrospective cohort study of 12,285 adult with newly diagnosed patients with heart failure fatigue was clinically documented in 39% (n=4827) participants.10
Edema
Edema is another common symptom of HF. Due to the reduced efficiency of the heart muscle in HF, blood fails to fully return to the heart leading to edema.3,11 Though edema can occur throughout the body, patients with HF most commonly present with peripheral edema. Edema is most commonly documented in the ankle and feet of patient with HF.8 In a nested case control study consisting of 86,882 patients from the clinical practice research datalink an analysis was conducted to determine how symptoms and signs recorded in routine primary care consultations after a new heart failure diagnosis relate to patients’ risk of hospitalization and death within the following three months. The study found that in the 3 months prior to hospitalization peripheral edema was observed in 8.6% of cases versus 5.3% of controls. or specific causes of hospitalization, the most prevalent symptoms and signs prior to HF hospitalization compared with controls were SOB (36.8% vs 16.6%) and peripheral oedema (14.5% vs 6.5%). Edema was reported in 8.9% of patients who died compared with 5.4% of matched controls.5 Most often peripheral edema is shown.
Other symptoms
Other less typical symptoms that occurs in patients with HF are coughing, wheezing, loss of appetite, depression, dizziness, syncope and a bloated feeling. 1,8
References
- Hollenberg SM, Stevenson LW, Ahmad T, et al. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure. JACC. 2019;74(15):1966-2011. doi:doi:10.1016/j.jacc.2019.08.001
- Jurgens CY, Lee CS, Aycock DM, et al. State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association. Circulation. 2022;146(12):e173-e184. doi:doi:10.1161/CIR.0000000000001089
- Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. doi:doi:10.1161/CIR.0000000000001063
- Yancy CW, Lopatin M, Stevenson LW, Marco TD, Fonarow GC. Clinical Presentation, Management, and In-Hospital Outcomes of Patients Admitted With Acute Decompensated Heart Failure With Preserved Systolic Function. JACC. 2006;47(1):76-84. doi:doi:10.1016/j.jacc.2005.09.022
- Ali MR, Lam CSP, Strömberg A, et al. Symptoms and signs in patients with heart failure: association with 3-month hospitalisation and mortality. Heart. 2024;110(8):578-585. doi:10.1136/heartjnl-2023-323295
- Barnes S, Gott M, Payne S, et al. Prevalence of Symptoms in a Community-Based Sample of Heart Failure Patients. Journal of Pain and Symptom Management. 2006;32(3):208-216. doi:10.1016/j.jpainsymman.2006.04.005
- Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of Symptom Prevalence and Symptom Burden on Quality of Life in Patients with Heart Failure. European Journal of Cardiovascular Nursing. 2005;4(3):198-206. doi:10.1016/j.ejcnurse.2005.03.010
- McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. Sep 21 2021;42(36):3599-3726. doi:10.1093/eurheartj/ehab368
- Smith OR, Kupper N, de Jonge P, Denollet J. Distinct trajectories of fatigue in chronic heart failure and their association with prognosis. Eur J Heart Fail. Aug 2010;12(8):841-8. doi:10.1093/eurjhf/hfq075
- Williams BA. The clinical epidemiology of fatigue in newly diagnosed heart failure. BMC Cardiovascular Disorders. 2017/05/11 2017;17(1):122. doi:10.1186/s12872-017-0555-9
- Kittleson MM, Panjrath GS, Amancherla K, et al. 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure With Preserved Ejection Fraction. Journal of the American College of Cardiology. 2023;81(18):1835-1878. doi:doi:10.1016/j.jacc.2023.03.393
