Cardiac Failure: Clinical Findings

A. Symptoms

The symptoms of cardiac failure have been discussed in part in earlier sections. The most common complaint is shortness of breath, chiefly exertional dyspnea at first and then progressing to orthopnea, paroxysmal nocturnal dyspnea, and rest dyspnea. A more subtle and often overlooked symptom of heart failure is a chronic nonproductive cough, which is often worse in the recumbent position. Nocturia due to excretion of fluid retained during the day and increased renal perfusion in the recumbent position is a common nonspecific symptom of heart failure. Patients with heart failure also complain of fatigue and exercise intolerance.

These symptoms correlate poorly with the degree of cardiac dysfunction and result in part from changes in peripheral blood flow and blood flow to skeletal muscle, which are part of the syndrome of heart failure. Patients with right heart failure may experience right upper quadrant pain due to passive congestion of the liver, loss of appetite and nausea due to edema of the gut or impaired gastrointestinal perfusion, and peripheral edema.

Cardiac failure may present acutely in a previously asymptomatic patient. Causes include myocardial infarction, myocarditis, and acute valvular regurgitation due to endocarditis or other conditions.

These patients usually present with pulmonary edema. The management of acute heart failure has been discussed under myocardial infarction and centers around initial stabilization with diuretics and parenteral vasodilators or inotropic agents.

Patients with episodic symptoms may be having left ventricular dysfunction due to intermittent ischemia. This potentially reversible form of heart failure should be considered, especially in patients with angina pectoris and those with diabetes mellitus. Patients may also present with acute exacerbations of chronic, stable heart failure. Exacerbations are usually caused by alterations in therapy (or patient noncompliance), excessive salt and fluid intake, arrhythmias, excessive activity, pulmonary emboli, intercurrent infection, or progression of the underlying disease.

Patients with heart failure are often categorized by the New York Heart Association classification as class I (asymptomatic), class II (symptomatic with moderate activity), class III (symptomatic with mild activity), or class IV (symptomatic at rest). However, this classification has major limitations in that patient reports are highly subjective and in that symptoms vary from day to day. In any case, the classification is insufficiently sensitive to be useful in predicting outcomes or assessing the results of treatment.

B. Signs

Many patients with heart failure, including some with severe symptoms, appear comfortable at rest. Others will be dyspneic during conversation or minor activity, and those with long-standing severe heart failure may appear cachectic or cyanotic. The vital signs may be normal, but tachycardia, hypotension, and reduced pulse pressure may be present. Patients often show signs of increased sympathetic nervous system activity, including cold extremities and diaphoresis. Important peripheral signs of heart failure can be detected by examination of the neck, the lungs, the abdomen, and the extremities. Right atrial pressure may be estimated through the height of the pulsations in the jugular venous system. In addition to the height of the venous pressure, abnormal pulsations such as regurgitant v waves should be sought. Examination of the carotid pulse may allow estimation of pulse pressure as well as detection of aortic stenosis. The thyroid examination is important, since occult hyperthyroidism and hypothyroidism are readily treatable causes of heart failure. In the lungs, crackles at the lung bases reflect transudation of fluid into the alveoli. Pleural effusions may cause bibasilar dullness to percussion. Expiratory wheezing and rhonchi may be signs of heart failure. Patients with severe right heart failure may have hepatic enlargement - tender or nontender - due to passive congestion. Systolic pulsations may be felt in tricuspid regurgitation. Sustained moderate pressure on the liver may increase jugular venous pressure (a positive hepatojugular reflux is an increase of > 1 cm). Ascites may also be present. Peripheral pitting edema is a common sign in patients with right heart failure and may extend into the thighs and abdominal wall.