Signs and Symptoms of Heart Failure: Are You Asking the Right Questions?

Albert, Nancy PhD, CCNS, CCRN, NE-BC
Trochelman, Kathleen RN, MSN
Li, Jianbo PhD
Lin, Songhua MS

About the Authors Nancy Albert is director of nursing research and innovation in the Nursing Institute and a clinical nurse specialist in the Kaufman Center for Heart Failure, Kathleen Trochelman is a nurse researcher in nursing research and innovation at the Nursing Institute, and Jianbo Li is a statistician and Songhua Lin is a statistical programmer, both in Quantitative Health Sciences, at Cleveland Clinic in Cleveland, Ohio. Corresponding author: Nancy Albert, PhD, CCNS, CCRN, NE-BC, FAHA, FCCM, Cleveland Clinic, 9500 Euclid Avenue, Mail code J3–4, Cleveland, OH 44195 (e-mail: [email protected]).

American Journal of Critical Care 19(5):p 443-453, September 2010. | DOI: 10.4037/ajcc2009314

Background

Patients may not verbalize common and atypical signs and symptoms of heart failure and may not understand their association with worsening disease and treatments.

Objectives

To examine prevalence of signs and symptoms relative to demographics, care setting, and functional class.

Methods

A convenience sample of 276 patients (164 ambulatory, 112 hospitalized) with systolic heart failure completed a 1-page checklist of signs and symptoms experienced in the preceding 7 days (ambulatory) or in the 7 days before hospitalization. Demographic and medical history data were collected.

Results

Mean age was 61.6 (SD, 14.8) years, 65% were male, 58% were white, and 45% had ischemic cardiomyopathy. Hospitalized patients reported more sudden weight gain, weight loss, severe cough, low/orthostatic blood pressure, profound fatigue, decreased exercise, restlessness/confusion, irregular pulse, and palpitations (all P<.05). Patients in functional class IV reported more atypical signs and symptoms of heart failure (severe cough, nausea/vomiting, diarrhea or loss of appetite, and restlessness, confusion, or fainting, all P≤.001). Sudden weight gain increased from 5% in functional class I to 37.5% in functional class IV (P<.001). Dyspnea occurred in all functional classes (98%-100%) and both settings (92%-100%). Profound fatigue was associated with worsening functional class (P<.001) and hospital setting (P=.001); paroxysmal nocturnal dyspnea was associated with functional class IV (P=.02) and hospital setting (P<.001).

Conclusion

Profound fatigue is more reliable than dyspnea as an indicator of functional class. Nurses must recognize atypical signs and symptoms of worsening functional class to determine clinical status and facilitate patient care decisions. (American Journal of Critical Care. 2010;19:443–453)

Notice to CE enrollees:

A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:

1. Recognize signs and atypical symptoms that may be associated with worsening heart failure and functional class.

2. Define key elements of a patient teaching plan related to heart failure and response to treatment.

3. Define reliable indicators of functional class for heart failure patients.

To read this article and take the CE test online, visit www.ajcconline.org and click “CE Articles in This Issue.” No CE test fee for AACN members.