20.3: Heart Failure III: Clinical Manifestations

Heart failure (HF) manifests primarily as dyspnea, fatigue, and fluid retention, resulting in peripheral and pulmonary edema. Symptoms may vary depending on which ventricle is more affected, left or right.

Left-Sided Heart Failure

Also known as left ventricular failure, this condition results from the left ventricle's inability to fill or eject sufficient blood into the systemic circulation. It leads to pulmonary congestion, which occurs when the left ventricle fails to eject blood effectively into the aorta. It increases left ventricular end-diastolic pressure, reducing blood flow from the left atrium and causing a buildup of blood volume and pressure in the left atrium and pulmonary veins. Fluid is then forced into the lung interstitium and alveoli, leading to pulmonary edema and impaired gas exchange.

Clinical Manifestations of Pulmonary Congestion

• Dyspnea: Shortness of breath occurring with minimal to moderate activity or even at rest. Orthopnea, or dyspnea while lying down, suggests heart failure. It occurs due to fluid redistribution from the legs to the lungs when recumbent and is relieved by sitting up. Paroxysmal nocturnal dyspnea (PND) is sudden nighttime dyspnea due to fluid accumulation in the pulmonary vessels entering the alveoli when supine.
• Cough: Initially dry and nonproductive, progressing to frothy, pink, or tan sputum in acute HF.
• Auscultation Findings: Pulmonary crackles and an extra heart sound (S3 or "ventricular gallop") due to abnormal ventricular filling.
• Other Symptoms include low oxygen saturation, fatigue, dizziness, confusion, pale or ashen skin, and cool, clammy extremities.

Other Manifestations of Left-Sided Heart Failure

The decrease in stroke volume (SV) stimulates the sympathetic nervous system to release catecholamines, which initially increase heart rate and contractility but eventually lead to impaired perfusion to many organs, including the kidneys.

• Renal Manifestations: Due to decreased renal perfusion, symptoms include decreased urinary output and nocturia.
• Gastrointestinal Manifestations: Decreased gastrointestinal perfusion causes altered digestion.
• Cerebral Manifestations: Decreased brain perfusion due to decreased oxygenation and blood flow leads to dizziness, lightheadedness, confusion, restlessness, and anxiety.

Right-Sided Heart Failure

Also known as right ventricular failure, this condition results from the right ventricle's inability to fill or eject sufficient blood into the pulmonary circulation. Increased venous pressure leads to congestion in peripheral tissues and viscera.

Clinical Manifestations of Right-Sided Heart Failure

• Jugular Venous Distention (JVD)
• Dependent Edema: Swelling in the lower extremities, progressing with prolonged standing or sitting and alleviated by leg elevation. Pitting edema becomes noticeable with significant fluid retention.
• Hepatomegaly and Ascites: Hepatomegaly refers to the enlargement of the liver, while ascites is the accumulation of fluid in the peritoneal cavity.
• Gastrointestinal Symptoms: These include anorexia, nausea, and abdominal pain due to venous engorgement.
• Weight Gain: Due to fluid retention.

Congestive Heart Failure

This term is used when both left and right heart failure symptoms are present. Failure of the left ventricle increases fluid pressure transferred back through the lungs, damaging the right side of the heart, which then loses its pumping power. Blood backs up in the venous system, causing swelling in the legs, ankles, and abdomen.

Pulmonary Edema

An episode of acute decompensated heart failure often occurs following an acute myocardial infarction or worsening of chronic heart failure. Blood backs up into the pulmonary circulation, leading to pulmonary edema. Symptoms include restlessness, anxiety, sudden onset of breathlessness, a feeling of suffocation, tachypnea, low oxygen saturation, pale or cyanotic skin, cool and clammy extremities, tachycardia, JVD, constant coughing with foamy sputum, and progressive confusion.