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ABC of heart failure - Clinical features and complications

Student BMJ; London Vol. 8,  (Mar 2000). DOI:10.1136/sbmj.000358

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Clinical features

Patients with heart failure present with a variety of symptoms, most of which are non.specific. The common symptoms of congestive heart failure include fatigue, dyspnoea, swollen ankles, and exercise intolerance, or symptoms that relate to the underlying cause. The accuracy of diagnosis by presenting clinical features alone, however, is often inadequate, particularly in women and elderly or obese patients.



Exertional breathlessness is a frequent presenting symptom in heart failure, although it is a common symptom in the general population, particularly in patients with pulmonary disease. Dyspnoea is therefore moderately sensitive, but poorly specific, for the presence of heart failure. Orthopnoea is a more specific symptom, although it has a low sensitivity and therefore has little predictive value. Paroxysmal nocturnal dyspnoea results from increased left ventricular filling pressures (due to nocturnal fluid redistribution and enhanced renal reabsorption) and therefore has a greater sensitivity and predictive value. Nocturnal ischaemic chest pain may also be a manifestation of heart failure, so left ventricular systolic dysfunction should be excluded in patients with recurrent nocturnal angina.

Fatigue and lethargy

Fatigue and lethargy in chronic heart failure are, in part, related to abnormalities in skeletal muscle, with premature muscle lactate release, impaired muscle blood flow, deficient endothelial function, and abnormalities in skeletal muscle structure and function. Reduced cerebral blood flow, when accompanied by abnormal sleep patterns, may occasionally lead to somnolence and confusion in severe chronic heart failure.


Swelling of ankles and feet is another common presenting feature, although there are numerous non.cardiac causes of this symptom. Right heart failure may manifest as oedema, right hypochondrial pain (liver distension), abdominal swelling (ascites), loss of appetite, and, rarely, malabsorption (bowel oedema). An increase in weight may be associated with fluid retention, although cardiac cachexia and weight loss are important markers of disease...