Why is it unsatisfactory to accept a diagnosis of “congestive heart failure” at face value? Why should you never simply put “congestive heart failure” in the problem list of your patient’s chart?

Congestive heart failure (CHF) is a very nonspecific term that refers to a failure of the heart to pump blood forward as well as it normally does. This leads to signs and symptoms related to back flow (or congestion) of blood, either to the lungs or the venous system. The term CHF is considered oversimplified and not reflective of the underlying etiology of pump failure. In the United States, the most common cause of CHF is coronary artery disease (CAD); however, there are many different causes of CHF, and it is important to the note the cause in your patient in order to best determine a treatment plan.

When charting on your patient with this clinical syndrome, it is important to note a few things. First, make sure to indicate the patient’s ejection fraction (EF) and the date of his or her most recent echocardiogram. Remember, not all patients with CHF have a depressed EF. In fact, approximately half of patients with CHF have a preserved EF and are classified as having heart failure with persevered EF (HFpEF). (The other broad category of CHF is heart failure with reduced EF [HFrEF]). Second, if known, make sure to specify the etiology of the heart failure. Third, note the functional capacity of the patient using the New York Heart Association (NYHA) classification (heart.org). All of these notations in the chart have implications on the treatment, either medical or surgical, of your patient. Charting can no doubt seem cumbersome at times; however, it remains a powerful tool in explaining your medical decision making and communicating with other providers that will be reading it. This is ultimately of most benefit to your patients.

What symptoms are suggestive of CHF?

The symptoms that a patient with CHF reports will depend on the underlying etiology and the side of the heart that is failing. Shortness of breath is the main symptom reported in CHF due to left-sided heart disease. Shortness of breath initially occurs with exertion, and as the disease becomes more severe can be present at rest. As blood backs up due to poor forward flow and congests the pulmonary vasculature, pressure inside the intrapulmonary capillaries is exceeded, and fluid leaks into the interstitial and alveolar spaces. On a related note, orthopnea, which is defined as shortness of breath from pulmonary edema when lying flat, is caused by redistribution of blood from the lower extremities and splanchnic vessels to the vena cava when recumbent. Remember to ask your patients how many pillows they need to prop themselves up on at night to prevent shortness of breath. If this number has increased recently, this can be a clue to worsening or exacerbated CHF. Also due to similar pathophysiology, coughing and wheezing at night (cardiac asthma), are often overlooked symptoms of CHF that can be mistakenly attributed to other conditions (such as asthma, gastroesophageal reflux, or infection). Paroxysmal nocturnal dyspnea (PND) is the sudden, intense sensation of shortness of breath that causes patients to wake up in the middle of the night gasping for air and is also related to pulmonary edema in the recumbent position. The main symptom of right-sided heart failure is lower extremity swelling, which is due to leaked fluid from increased capillary pressure in the extremities from venous congestion. Other nonspecific symptoms that can be attributed to CHF are fatigue, nausea, vomiting, and early satiety due to bowel wall edema.

What signs are seen in CHF?

The signs of CHF depend on the underlying etiology and the severity of the disease. In general, patients with mild or well-controlled CHF will appear normal at rest but can appear tachy­pneic with exertion. Upon exam of the lungs, crackles or rales are indicative of intraalveolar fluid and decreased breath sounds are due to pleural effusions. Rales and decreased breath sounds are often bilateral, but patients can have unilateral pleural effusions, usually in the right hemithorax.

The heart exam can vary widely and often sounds normal. Make sure to feel for lifts and thrills and to palpate for the point of maximal impulse (PMI), which if displaced can signify an enlarged heart. Gallops are extra heart sounds (in addition to the normal S1 and S2) that can be heard in CHF patients, but their absence does not mean a patient does not have CHF. S3 is a third heart sound that occurs after S1 and before S2 and is caused by blood sloshing around in dilated ventricles. S4, or the fourth heart sound, occurs before S1 and represents blood being forcefully ejected into a noncompliant or “stiff” ventricle (which one may have with left ventricular hypertrophy, hypertrophic cardiomyopathy, or restrictive heart disease of any cause).

The exam of the extremities can reveal pitting edema in the feet, ankles, or legs caused by interstitial fluid that has leaked out of the capillaries from venous congestion due to right-sided heart failure. The term pitting refers to indentations (or pits) that form when pressure is applied to a swollen extremity.