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Clinical manifestations and diagnosis of advanced heart failure

Authors
Wilson S Colucci, MD
Shannon M Dunlay, MD, MS
Section Editor
Donna Mancini, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

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 [1]. (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".)

CLINICAL MANIFESTATIONS

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 [1]. 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".)

                          
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Literature review current through: Oct 2017. | This topic last updated: Jun 14, 2017.
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