Clinical manifestations and diagnosis of advanced heart failure
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
- Shannon M Dunlay, MD, MS
Shannon M Dunlay, MD, MS
- Associate Professor of Health Services Research and Medicine
- Mayo Clinic College of Medicine
Advanced heart failure (HF) occurs when patients with HF experience persistent severe symptoms that interfere with daily life despite maximum evidence-based medical therapy. Patients with advanced HF have alternatively been described as having "refractory," "end-stage," or "American College of Cardiology/American Heart Association stage D" HF . (See "Determining the etiology and severity of heart failure or cardiomyopathy", section on 'Stages in the development of HF'.)
An overview of the clinical manifestations and diagnosis of advanced HF will be presented here. The management of advanced HF, diagnosis and management of patients with suspected HF, and management of acute decompensated HF will be discussed separately. (See "Management of refractory heart failure with reduced ejection fraction" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment of acute decompensated heart failure: Components of therapy" and "Treatment of acute decompensated heart failure: General considerations" and "Epidemiology and causes of heart failure".)
Symptoms and signs — While signs and symptoms of advanced HF are variable, common manifestations of advanced HF include exercise intolerance, unintentional weight loss, refractory volume overload, as well as hypotension and signs of inadequate perfusion (eg, low pulse pressure). These signs and symptoms occur on maximum evidence-based medical therapy, following insertion of all appropriate devices (eg, cardiac synchronization therapy) and with all reversible causes of HF addressed. These patients frequently experience recurrent hospitalizations.
Mortality risk increases with each subsequent HF hospitalization [2,3]. The presence of repeated hospitalizations (≥2 in six months) or complicated hospitalizations (eg, requiring intensive care unit care or inotropes) can suggest advanced HF.
Dyspnea, fatigue, and exercise intolerance — As HF progresses, patients frequently develop symptoms such as dyspnea, lightheadedness, or fatigue at rest or with minimal exertion that limits exercise capacity. Patients with advanced HF generally exhibit New York Heart Association (NYHA) functional class III (symptoms with minimal exertion) or IV (symptoms at rest or with any activity) symptoms (table 1). Since normal exercise capacity varies based on individual factors, such as age and activity level, standard benchmarks for exercise capacity may not be suitable for individual patients. Thus, a patient’s report of decline in exercise capacity over time can be most informative in signaling a significant change in exercise capacity. However, exercise limitation that is worrisome for advanced HF includes inability to walk a city block or perform activities of daily living such as bathing or dressing without limiting symptoms . Many patients will progress to have dyspnea at rest, including at night (orthopnea, paroxysmal nocturnal dyspnea). Poor functional status is an adverse prognostic indicator in patients with HF. (See "Predictors of survival in heart failure with reduced ejection fraction".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- CLINICAL MANIFESTATIONS
- Symptoms and signs
- - Dyspnea, fatigue, and exercise intolerance
- - Unintentional weight loss
- - Refractory volume overload
- - Hypotension and signs of inadequate perfusion
- Initial tests
- - Blood tests
- Poor or worsening renal function
- Congestive hepatopathy
- Elevated serum natriuretic peptide levels
- - Chest radiograph
- - Electrocardiogram
- DIAGNOSIS AND EVALUATION
- When to suspect advanced heart failure
- Approach to diagnosis and evaluation
- How to diagnose advanced heart failure
- Key tests
- - Echocardiography
- - Exercise testing
- - Right heart catheterization
- Evaluation for reversible causes and contributing factors
- Differential diagnosis
- - Inadequate therapy
- - Concurrent conditions
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS