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Congestive Heart Failure |
Today we're talking about the signs and symptoms of congestive heart failure. Before we discuss those signs and symptoms, let's talk about what congestive heart failure is so we can better understand why the signs and symptoms occur.
Congestive heart failure is a condition involving an inability of the heart to pump blood effectively. Generally speaking, it's due to damage to the heart muscle, which is also known as the myocardium. You can imagine that if there’s damage to the heart muscle, it’s not going to be able to contract and pump blood effectively, so it’s not going to be able to push blood to places where it’s supposed to go.
Now, there are a variety of risk factors for getting congestive heart failure. We’re going to talk about them here very quickly, but if you want more information, please check my full lesson on congestive heart failure. Some of the risk factors for getting congestive heart failure include coronary artery disease, previous myocardial infarction (which is a heart attack), diabetes, valvular heart disease, alcoholism (which is often due to chronic heavy alcohol consumption), hypertension (which is high blood pressure, often a chronic history of high blood pressure), and sleep-disordered breathing (conditions like sleep apnea).
In order to understand the signs and symptoms of congestive heart failure, we actually break down the heart into the right heart and the left heart. So, we’ll quickly talk about the anatomy of the heart here. On the right heart, if we’re looking directly at the patient, this is the right side and this is the left side. The right side of the heart brings blood from the rest of the body; it’s going to be deoxygenated blood from the superior vena cava and the inferior vena cava into the right atrium, which then brings that blood into the right ventricle. The right ventricle contracts and pushes blood through the pulmonic valve into the pulmonary arteries. These are actually called arteries even though they still carry deoxygenated blood, and that blood is going to go to the lungs and then become oxygenated.
Then, the oxygenated blood comes back into the left heart through four pulmonary veins into the left atrium. The left atrium then brings blood into the left ventricle, and that left ventricle contracts and pushes that blood through the aortic valve into the aorta to supply the rest of the body with oxygenated blood.
Knowing that anatomy, if we were to say that there is right heart failure, it means the right side of the heart doesn’t contract properly. For instance, there may be some damage to the myocardium on the right side of the heart. Blood is continually being brought back into the right atrium and the right ventricle, but if it’s not being pushed through the pulmonic valve and into the pulmonary arteries, it starts to back up into the superior and inferior vena cava and into other parts of the venous system.
On the other side, if it’s left heart failure, that means that blood is coming in from those pulmonary veins. If that left side of the heart is not pumping blood effectively, it means that there’s blood continuing to come in, but it’s not being pushed through the aortic valve and into the aorta to supply the rest of the body. So, that blood starts to back up into those pulmonary veins and ultimately into the lungs, which is why we’re going to see the signs and symptoms we’re going to talk about in this lesson.
If it’s right-sided heart failure, the body is going to show signs and symptoms. Whereas if it is left-sided heart failure, then what that means is that blood is being backed up into those pulmonary veins and into the lungs, so it’s going to primarily involve lung symptoms. Even though I break it down into right-sided and left-sided heart failure, oftentimes patients will have both sides of the heart affected. Because of both of the effects that we talked about here, we’re going to have a variety of signs and symptoms and clinical findings that occur in congestive heart failure.
I want to talk about those and why they occur as we go through this lesson. So, we’re first going to talk about left-sided heart failure. Left-sided heart failure is going to have three very characteristic and hallmark findings that are often brought up and talked about in clinical practice.These are going to include dyspnea on exertion. Dyspnea is simply shortness of breath, and exertion is going to be during physical activity. So, shortness of breath on exertion or activity is going to be compared to baseline, meaning it’s going to be compared to what was before the congestive heart failure.
A classic example is if they have shortness of breath when walking up a flight of stairs when before they didn’t have this issue. It can start out with dyspnea on exertion, but it can progress and become worsened to the point where there’s dyspnea at rest or shortness of breath at rest. Another classic finding with left-sided heart failure is orthopnea. Orthopnea is going to be shortness of breath when lying down flat.
Now, this is going to be key: lying down flat is going to be the problem. What’s often noted is that the patient is going to require multiple pillows to catch their breath. If you have multiple pillows, it sort of pushes the patient upward at an angle. The reason that this is important is that if the patient is lying flat, there’s going to be fluid in the lungs due to that backing up of blood into the lungs. The backing up of blood into the lungs from that left-sided heart failure is going to lead to pulmonary edema.
There’s going to be fluid that starts to back up into some of the other structures in the lungs. If you’re lying down flat, gravity is going to flatten out that fluid to cover the majority of the lung surface area. In the case of using multiple pillows, the patient’s head is propped up at an angle, and gravity is going to bring that fluid down to other surface areas of the lungs that are not affected. This is the reason why using multiple pillows is helpful for these patients.
Another important clinical finding with left-sided heart failure is something called proximal nocturnal dyspnea or PND. This is where the patient wakes up in the middle of the night gasping for air. They’re sleeping, and all of a sudden, they wake up and they are short of breath; they can’t catch their breath. A classic story for a patient with proximal nocturnal dyspnea would be that they wake up all of a sudden in the middle of the night gasping for air and they run to a window and open it to catch their breath.
Some other signs and symptoms of left-sided heart failure include coughing. Coughing is going to occur in addition to the shortness of breath, and it’s often going to be persistent and productive, meaning they can cough up some mucus. This is going to be due to pulmonary edema, like all these findings we see with left-sided heart failure. Some other lung findings that we can find include crackles on auscultation. If you were to auscultate or use your stethoscope and check the lung areas, you’re going to hear crackling, popping noises, and that’s going to be due to pulmonary edema from all that fluid built up from the backing up of blood that’s not being pumped effectively from the left side of the heart.
So those are some of the lung findings we’re going to see with left-sided heart failure. Now, let’s talk about right-sided heart failure. Right-sided heart failure is again going to be due to the right side of the heart not pumping blood effectively, and that’s going to lead to a backing up of deoxygenated blood into the superior and inferior vena cava and into other parts of the venous system. This is going to lead to peripheral edema, which is going to look like swelling of the extremities. Again, this is going to occur with right-sided heart failure.
Another important finding with right-sided heart failure is distended jugular veins, which we call the JVP or jugular venous pressure.