The signs and symptoms of heart failure may vary substantially in seriousness and type. The clinical manifestations of heart failure reflect the degree of cardiac pump impairment as well as the effectiveness and magnitude of compensatory responses. The heart itself produces no symptoms as it begins to fail. The characteristic symptoms of heart failure are the consequence of the physiological impairments of the lungs, kidneys, liver, skeletal muscles, and other organ systems. These symptoms often begin slowly and progress in severity. At first, they may only be evident during strenuous physical exertion. Over time, you may suffer breathing problems and other symptoms even when you are lying down and resting. The pathophysiology of heart failure (decreased cardiac output and fluid retention) predicts many of the clinical manifestations arising in association with this disorder.1

Specific Symptoms of Heart Failure

  • Shortness of breath (dyspnea) during physical activity is the most prevalent and earliest symptom of HF. Gradually, shortness of breath occurs when lying at rest (orthopnea). When the patient with heart failure is in the upright position, gravity reduces the venous pressure in the lungs above the level of the heart. This effect is lost when the patient is lying flat due to a redistribution of blood volume from the lower extremities and splanchnic circulation (gastric, small intestinal, colonic, pancreatic, hepatic and splenic circulations) to the lungs. This is particularly true at night (paroxysmal nocturnal dyspnea) when increasing amounts of fluid enter the lungs resulting in a sudden attack of breathlessness that awakens the patient usually 2 to 4 hours after the onset of sleep.
  •  Fatigue, weakness, faintness
  •  Swollen feet or ankles (pedal edema)
  •  Reduced exercise tolerance

Less Specific Presentations of Heart Failure

  • Wheezing or cough
  • Pulse that feels fast or irregular or a sensation of feeling the heartbeat  (palpitations)
  • Symptoms that result from inadequate blood delivery to the abdominal organs that may affect nutritional status include:
    1. anorexia (loss of appetite)
    2. early satiety
    3. nausea
    4. feeling of fullness
    5. constipation
    6. abdominal pain
    7. malabsorption
    8. enlarged liver and liver tenderness
  •  Need to urinate at night
  •  Decreased cerebral blood flow can lead to mental confusion, disorientation, memory loss, anxiety, sleeplessness and headaches
  •  Unexplained weight gain of more than 2 kg/week (may be a sign of fluid accumulation)
  •  Depression (especially in the elderly)
  •  Cool extremities, sweating



Reference List

1.  Task FM, McMurray JJV, Adamopoulos S et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012;33:1787-1847.