If you have heart failure, symptoms
start to happen when your heart cannot pump enough blood to the rest of your
While shortness of breath is the most common symptom of heart
failure, it may be difficult or impossible to distinguish it from shortness of
breath caused by other health problems such as emphysema or severe anemia. Your
doctor can help you determine why you have been feeling short of breath.
People with heart failure experience shortness of breath in many
different ways. You might feel that:
Shortness of breath from exertion or exercise. If your
shortness of breath isn't severe, you may notice it only when you are exerting
yourself, and sometimes only during more intense exertion. The medical term
for this symptom is dyspnea (say "DISP-nee-uh").
When heart failure develops gradually, your shortness of breath also
may develop gradually, which can make it hard to notice. But people with more
severe heart failure may have shortness of breath with minimal
Shortness of breath while lying down. People
with more severe heart failure may experience shortness of breath when they lie
down. The medical term for this symptom is orthopnea (say "or-THAWP-nee-uh"). The
severity of this symptom usually depends on how flat you are lying—the flatter
you lie, the more you feel short of breath.
To gauge the severity of this symptom, doctors often ask people how
many pillows they need to lie on to avoid feeling short of breath in bed. For
example, "three-pillow" orthopnea is worse than "two-pillow" orthopnea, because
you have less tolerance for lying flat.
The reason you may have orthopnea is that when you lie flat, the
blood that ordinarily pools in the veins of your legs is reentering your
bloodstream. If you have heart failure, your heart may not be able to keep up
with the increased amount of blood returning to the heart, so fluid builds up
inside the lungs and causes shortness of breath.
Shortness of breath while sleeping. Some
people with heart failure wake up in the middle of the night with severe
shortness of breath. The medical term for this symptom is paroxysmal nocturnal
dyspnea (PND). This may occur with waking up
coughing and/or wheezing, having a rapid heart rate, and a feeling of being
In general, people who experience PND don't feel increased
shortness of breath when they first lie down. But after several hours of
lying down, they awake with shortness of breath, which often occurs suddenly.
People who experience PND often have to sit up on the side of the bed, and they
may feel a need to open a window to get more air. The shortness of breath
generally goes away after a few minutes of sitting up.
You might feel that:
You might also have
low exercise capacity. This can be harder to describe. It is a symptom that
people with heart failure often don't even notice because they have gradually
reduced the level at which they exert themselves.
For example, they may stop walking up the stairs, or they may drive
to the store instead of walking. Some people at first deny that they have been
experiencing this symptom. It is only after doctors ask them about changes in
their activities that they realize they have been avoiding physical exertion.
This decrease in your ability to exert yourself physically is what doctors call
low exercise capacity.
heart failure often experience swelling in their
ankles or feet. You might notice that:
The degree of swelling you experience depends on how well your
body is compensating for heart failure and how much sodium and water your body
retains. In some cases the swelling is mild and merely bothersome, while in
other cases it can be severe and painful if the skin becomes taut and
The medical term for this swelling in the legs is pedal edema—"pedal"
refers to the feet and "edema" refers to the buildup of excess fluid. Heart
failure often causes what doctors call "pitting edema," meaning that applying
pressure to the swollen skin leaves an indentation in the skin. Doctors often
test for edema by pressing their thumb to the skin and seeing whether it leaves
an impression. You may see this yourself if you take off your shoes and socks
and find that your socks have left an impression in the skin of your ankles and
You may notice more
severe swelling if you have been eating too much salt, which causes your body
to retain fluid. Elevating your feet or wearing supportive stockings can help
relieve the swelling.
In the earlier stages of
heart failure, some people need to urinate more
frequently during the night than during the day. This happens because during
the day, fluid and blood can pool in your legs while you are standing,
resulting in less blood in the circulation and, as a result, less blood flow to
At night when you lie down, blood and fluid in your legs reenter the
circulation and therefore increase the blood flow to your kidneys and the
amount of urine produced.
If your heart failure gets worse, your kidneys receive less and less
blood, both during the day and at night. As a result, the kidneys produce less
urine. If you are urinating infrequently or not at all, tell your doctor right
away because it may mean that the amount of blood your heart is pumping is
Weight gain may be the first noticeable sign that you
have developed heart failure or that your heart failure is getting worse. The amount of weight gained varies greatly among people with heart failure, and it reflects the amount of sodium and water the body has retained.
A sudden weight gain may mean that excess fluid is building up in
your body because your heart failure is getting worse. It is a symptom of sudden heart failure.
Your doctor will probably ask you to weigh yourself every day. Know when to call your doctor if you suddenly gain weight.
Your doctor likely will work with you to manage changes in weight caused by fluid
retention. For example, if you have a weight increase of
2 lb (0.91 kg), your doctor may
recommend taking an additional diuretic that day.
April 26, 2012
Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology & Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology
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