Angie Houtz
Memorial Scholarship Fund

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Symptoms and Signs of Heart Failure

In general, the symptoms and signs of HF are derived from the following physiopathological disorders:

  • increased pulmonary and systemic venocapillary pressures,
  • limitation and redistribution of cardiac output;
  • sympathetic hyperactivity;
  • hyperactivity of the renin-angiotensin-aldosterone system;
  • increase in volume and total Na.

The following are the main symptoms of heart failure:


It is the most characteristic symptom of heart failure, but it can be present in many other pathologies. We define it as a “sensation of respiratory distress.” Patients describe it as “shortness of breath,” “choking,” “agitation,” “fatigue,” etc. It is due to the increase in respiratory work, which can have many causes: increased resistance to airflow, disorders of respiratory mechanics, increased stimuli of the respiratory center, etc.

In heart failure, the most critical factor is the increase in the pulmonary interstitial fluid content, due to left atrial hypertension, which produces an increase in pulmonary rigidity and respiratory work. Further, In more advanced cases there may be a compromise of intercostal muscle masses and decreased muscle blood flow, which produces early muscle exhaustion. There is usually no deficit of oxygen saturation and only discrete degrees of hyperventilation.

The degree of dyspnea allows classifying heart failure, according to the magnitude of the effort that triggers it, in 4 degrees of functional commitment: (Criteria of the New York Heart Assoc.)

  • Functional Capacity I = There is a cardiac pathology, but physical efforts only produce a physiological dyspnea. Without functional limitation.
  • Functional Capacity II = Dyspnea appears with moderate efforts and is accompanied by a mild/moderate functional restriction.
  • Functional Capacity III = Dyspnea appears with minor efforts, producing an essential functional limitation.
  • Functional Capacity IV = There is dyspnea at rest or with minimal efforts. Maximum functional restriction.

Rea more about dyspnea on exertion here. Orthopnea

It is the appearance of dyspnea in dorsal decubitus, which leads the patient to sit on his bed. It is because pulmonary capillary hypertension increases in the decubitus position, by increasing the pulmonary blood volume. Also influences the fact that ventilatory mechanics is less efficient in that situation.

Nocturnal Paroxysmal Dyspnea

They are a crisis of dyspnea during sleep, which forces the patient to take the ortopnoic position. It is explained by several factors: the decreased activity of the respiratory center during sleep, increased blood volume and pulmonary capillary pressure in decubitus and is accentuated by reabsorption of edema during the night, respiratory mechanics poorer, decreased tone sympathetically, etc. It may present as nocturnal cough and occasionally as episodes of bronchospasm (“cardiac asthma”) due to bronchiolar edema.

Acute pulmonary edema

It is the most severe expression of pulmonary capillary hypertension. It is accompanied by extravasation of blood to the alveoli and eventually to the bronchi, producing hemoptysis. It is usually associated with a deterioration of gas exchange, with hypoxemia and a significant increase in respiratory work. It is a clinical situation that tends to worsen and can cause the death of the patient, due to hypoxia and respiratory exhaustion, in a few hours.

Peripheral edema

It usually is predominantly evening and tends to diminish or disappear during the night. It is located in the decubitus areas: the pretibial region in ambulatory subjects or sacral region in patients in bed. Its origin is multifactorial, being the most important the increases of the venous pressure, of the total Na and the volemia.


It is the increase in nocturnal diuresis, which is explained by reabsorption of edema.


This symptom is more non-specific than dyspnea. It is attributed to decreased muscle perfusion and muscle atrophy at rest, which determines early muscle fatigue.


It is the perception of the heartbeat and can occur in typical situations. The patient with heart failure usually reports that along with dyspnea he/she notices faster heartbeats.

Anorexia and epigastric discomfort

They usually occur in patients with visceral congestion due to venous hypertension.