Signs and Symptoms of Congestive Heart Failure

Signs and symptoms of congestive heart failure (CHF) include:

• Exertional dyspnea - shortness of breath, coughing, or a sensation of not being able to draw a deep breath. Exertional dyspnea is usually an early symptom.
• Shortness of breath or difficulty breathing when lying down as fluid backs up into the lungs.
• Sensation of exacerbation of existing pulmonary conditions such as asthma or chronic obstructive pulmonary disease (COPD)
• Lower extremity swelling - swelling of the ankles and legs (edema) and/or accumulation of fluid in the abdomen (ascites) due to excess fluid congestion in the liver.
• Fatigue and lethargy
• Dry, hacking cough
• Increased urination at night
• Heart palpitations due to the heartbeat speeding up in order to pump out more blood. In addition, heart failure can cause changes to the heart's electrical conduction system, which results in irregular heartbeats.

Many elderly people with congestive heart failure may experience additional symptoms including:

• Confusion
• Memory impairment
• Feeling drowsy or sleepy
• Decreased level of activity
• Loss of appetite
• Irritability
• Depression

Differential Diagnosis of Congestive Heart Failure

Patients who present with shortness of breath must be differentiated from those with primary diseases of the lungs such as emphysema or other types of chronic pulmonary disease. Other conditions that may cause shortness of breath or coughing include:

• Infection (such as pneumonia)
• Pulmonary embolism (blood clot in the lungs)
• Liver disease
• Kidney disease
• Blood clot in the leg or groin
• Mass in the lower abdomen

Diagnostic Testing for Congestive Heart Failure

The American College of Physicians (ACP) recommends the following tests to evaluate any patient with suspected heart failure:

• Electrocardiogram (EKG) - An electrocardiogram is recommended for any patient at risk for, or with a history of cardiac disease, including new onset or exacerbated heart failure. An EKG reveals:
  • ventricular hypertrophy (enlargement of the ventricle)
  • atrial abnormalities
  • arrythmias
  • conduction abnormalities
  • previous heart attack
  • active ischemia
• Echocardiogram - two-dimensional echocardiography with Doppler is a special ultrasound study of the heart that uses sound waves to image the heart and the blood vessels leading to it in "real-time". The American Academy of Family Physicians recommends an echocardiogram in all patients suspected of heart failure. It is a key test to evaluate left ventricular dysfunction in order to differentiate between systolic and diastolic dysfunction (heart failure in the presence of preserved left ventricular function). In addition, an echocardiogram with Doppler also shows:
  • heart-valve abnormalities
  • left ventricular cavity size and function
  • abnormal motion in the ventricular wall
  • left ventricular ejection fraction
  • right ventricular function

Other diagnostic tests that may be performed in select patients with CHF include:

• X-ray of the chest, which may show fluid in the lungs, enlargement of the heart (cardiomegaly) and other findings that may suggest congestive heart failure.
• Stress test (walking on a treadmill) to detect myocardial ischemia (reduced blood flow to the heart). A stress test may be combined with nuclear imaging or echocardiography. Information from a stress test includes:
  • exercise-induced arrhythmia
  • quantification of the functional capacity of the heart
• Nuclear ventriculography - a special imaging modality that uses radioactive tracers to view the chambers of the heart and the blood vessels
• Contrast angiography - use of a contrast material with magnetic resonance imaging (MRI), computed tomography (CT), or X-ray to produce images of major blood vessels
• Cardiac catheterization - used if the echocardiogram does not clearly define the severity of valve disease or if ischemic heart disease (lack of adequate blood supply) due to blockage is suspected.

Laboratory testing may include: