Clinical Assessment of Patients
with Heart Failure
The symptoms and signs of Heart Failure
(HF) are often difficult to identify because they are
frequently confused with other disorders or are attributed
to aging, obesity, or lack of physical conditioning.
Limitation of exercise tolerance may be so gradual that
patients may consciously or subconsciously adapt their
lifestyle to minimize symptoms and fail to report them
to physicians. Therefore, patients should be advised
to inform their heath care providers about limitation
of exercise tolerance or unexplained fatigue and physicians
should intensify their vigilance for the signs and symptoms
of HF in such individuals.1
HF is largely a clinical diagnosis
that is based on a careful history and physical examination.
The approach that is most commonly used to quantify
the degree of functional limitation imposed by HF is
one first developed by the New York Heart Association
(NYHA).1,2
| Class |
Degree of effort needed to elicit
symptoms |
| I |
No limitation; ordinary exercise does
not cause fatigue, dyspnea or palpitations |
| II |
Slight limitation of physical activity;
comfortable at rest, but ordinary activity results
in fatigue, palpitations or dyspnea |
| III |
Marked limitation of physical activity;
comfortable at rest, but less than ordinary activity
results in symptoms |
| IV |
Unable to carry out any physical activity
without discomfort; symptoms of heart failure are
present even at rest with increased discomfort with
any physical activity |
The evolution and progression of
HF can also be appropriately characterized by the four
stages of disease noted below, which are intended to
complement, but not replace the NYHA functional classification.
Patients with HF are expected to advance from one stage
to the next, unless progression of the disease is slowed
or stopped by treatment.1
Stages of Heart Failure1
| Stage |
Description |
Examples |
| A |
Patients
at high risk of developing HF because
of the presence of conditions that are strongly
associated with the development of HF. Such patients
have no identified structural or functional abnormalities
of the pericardium, myocardium or cardiac valves
and have never shown signs or symptoms of HF |
Systemic hypertension; coronary artery
disease; diabetes mellitus; history of cardiotoxic
drug therapy or alcohol abuse; personal history
of rheumatic fever; family history of cardiomyopathy |
| B |
Patients who have developed structural
heart disease that is
strongly associated with the development of HF,
but who have never shown signs of symptoms of HF |
Left ventricular hypertrophy or fibrosis;
left ventricular dilatation or hypocontractility;
asymptomatic valvular heart disease; previous myocardial
infarction |
| C |
Patients
who have current or prior symptoms of HF
associated with underlying structural heart disease |
Dyspnea or fatigue due to left ventricular
systolic dysfunction; asymptomatic patients who
are undergoing treatment for prior symptoms of HF |
| D |
Patients
with advanced structural heart disease and
marked symptoms of HF at rest, despite maximal medical
therapy and who require specialized interventions |
Patients who are frequently hospitalized
for HF or cannot be safely discharged from the hospital;
patients in the hospital awaiting heart transplantation;
patients at home receiving continuous intravenous
support for symptom relief or being supported with
a mechanical circulatory assist device; patients
in a hospice setting for the management of HF |
There is a poor relationship between symptoms and the
severity of cardiac dysfunction and between symptoms
and prognosis.2 Although the functional class
tends to deteriorate over periods of time, most patients
with HF do not typically show an uninterrupted and inexorable
worsening of symptoms. Instead, the severity of symptoms
characteristically fluctuates even in the absence of
changes in medications, and changes in medications and
diet can have marked favorable or adverse effects on
functional capacity in the absence of measurable changes
in ventricular function.1
Although HF is generally regarded
as a hemostatic disorder, many studies have indicated
that there is a poor relation between cardiac performance
and the symptoms produced by the disease. Patients with
a very low ejection fraction are frequently asymptomatic,
whereas patients with preserved left ventricular systolic
function may have severe disease.1
For more information, click on the
following subjects:
Clinical Assessment of Patients with Heart Failure
Identification
of a Structural Abnormality
Evaluating
the Cause of Ventricular Dysfunction
The Role of
Natriuretic Peptides
Reference
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