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Health Protocols

Heart Failure

What are the Signs and Symptoms of Heart Failure?

Some of the most prominent symptoms of heart failure are listed below.61 Some symptoms may not be apparent in mild heart failure, but will emerge as heart failure advances to moderate or severe stages.

  • Fatigue and difficulty breathing (dyspnea), which can lead to decreased capacity for physical activity (exercise intolerance). In cases of mild heart failure, it may be difficult to breathe during physical activity, while in advanced heart failure it may be difficult for patients to breathe even at rest.
  • Fluid retention, which may result in peripheral or pulmonary edema.28 However, not all people with heart failure will exhibit both exercise intolerance and edema.
  • Frequent nighttime urination (nocturia).
  • Rapid or irregular heartbeat.
  • Lack of appetite or nausea.
  • Decreased mental alertness or difficulty concentrating.
  • In advanced heart failure, wheezing, cough that produces pink-tinged frothy sputum, abdominal discomfort or swelling, anorexia, and weight loss may occur.

Some signs that may suggest heart failure include changes in heart size (cardiomegaly) and/or rhythm, impaired lung function, evidence of low blood oxygen, and abdominal swelling. These signs are typically progressive with the severity of heart failure.2

Classification and Staging of Heart Failure

Classifying heart failure on the basis of severity and clinical manifestations helps clarify what kinds of interventions may be necessary and what the prognosis may be. The New York Heart Association (NYHA) Functional Classification classifies patients with cardiac disease into one of four classes, based on symptoms and their degree of comfort at different levels of physical activity.

NYHA Functional Classification

  • Class I patients have no physical limitations or any symptoms such as fatigue, palpitations, breathlessness, or chest pain.
  • Class II patients are comfortable at rest and can typically perform everyday activities. Physical activity may result in fatigue, palpitations, breathlessness, or chest pain.
  • Class III patients are comfortable at rest, but everyday activities cause fatigue, palpitations, breathlessness, or chest pain.
  • Class IV patients cannot engage in any physical activity without discomfort. Symptoms of heart failure or chest pain may be present even at rest.62

Although the NYHA classification system helps cardiologists guide therapy for individual patients, it is subject to inter-observer variability. A second approach to heart failure classification was developed by the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines and is sometime used to supplement NYHA classification in the clinical setting.63,64

This system accounts for both the development and progression of heart failure.63 It identifies four stages, the first two (A and B) of which are not considered overt heart failure, but rather risk factors that predispose to heart failure. This scale attempts to help healthcare providers identify at-risk patients early.28

American College of Cardiology Foundation/American Heart Association Staging

At Risk for Heart Failure

  • Stage A. These patients are at a high risk for heart failure, but do not have structural disease or symptoms of heart failure. This includes those with coronary artery disease or diabetes.
  • Stage B. This stage includes those who have structural heart disease, such as left ventricular hypertrophy/dysfunction or chamber enlargement, but who do not have signs or symptoms of heart failure.

Heart Failure

  • Stage C. These patients have structural heart disease with prior or current symptoms of clinical heart failure.
  • Stage D. These patients have treatment-resistant heart failure requiring specialized intervention, such as transplantation, biventricular pacemakers, or left ventricle assist devices.28

Note that in the ACCF/AHA classification system, a patient cannot move backwards to a prior stage. That is, once a patient is classified as Stage C, they cannot be in Stage B again. In the NYHA system, which is based solely on symptoms, patients can move between classes.65

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