Fast Five Quiz: Heart Failure Presentation and Diagnosis

Yasmine S. Ali, MD


December 02, 2021

Figure 1. Color x-ray of heart.

One of the cardinal symptoms of LV (systolic) heart failure is dyspnea. Dyspnea experienced by patients with LV heart failure is progressive and worsens with advancing heart failure in the following order:

Exertional dyspnea develops in the early stages of heart failure. Patients with exertional dyspnea often experience mild to moderate breathlessness associated with activities; as the heart failure progresses, patients perform fewer physical activities because of worsening dyspnea. Exertional dyspnea typically resolves within minutes on cessation of the activity.

Orthopnea is dyspnea that occurs when patients are in a recumbent position. Orthopnea occurs within a few minutes of lying down, while the patient is awake, and is relieved when the head and chest are elevated with pillows. The change in the number of pillows required to breathe comfortably is an important sign of the severity of the patient's orthopnea. Similar to exertional dyspnea, orthopnea progressively worsens through the course of heart failure, but resolves in minutes on positional correction (eg, sitting up in bed).

The presence of a nonproductive cough while lying down is considered an orthopnea equivalent, and resolves with heart failure treatment.

Paroxysmal nocturnal dyspnea is a sudden waking from sleep, in which patients experience a sensation of panic and suffocation, often accompanied by bronchospasm and continued dyspnea. Similar to orthopnea, symptoms of paroxysmal nocturnal dyspnea resolve when patients sit up in bed; however, the time to complete resolution of symptoms may be 30 minutes or more.

Dyspnea at rest in heart failure results from decreased lung function caused by decreased lung compliance and increased airway resistance, increased ventilatory drive from hypoxemia, and respiratory muscle dysfunction (decreased respiratory muscle strength, decreased endurance, and ischemia).

Acute pulmonary edema is sudden LV failure that results in a sudden increase in pulmonary capillary wedge pressure greater than 25 mm Hg.

Although chest pain, confusion, weakness, and abdominal swelling can present in patients with heart failure, none of these is the cardinal symptom of heart failure. Paresthesias in the hands and feet can be a symptom of peripheral artery disease (PAD), which affects the circulatory system, causing blood vessels to become narrower. This may lead to poor circulation, which can cause tingling in the hands and feet.

Learn more about dyspnea in heart failure.


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