Heart Failure

Heart failure is a pump problem, and fluid backs up behind the side that is failing. If you hold onto that single sentence you can reconstruct the entire symptom picture without memorising two separate lists.

The left ventricle sends blood to the body. When it fails, blood backs up behind it into the lungs. The right ventricle sends blood to the lungs. When it fails, blood backs up behind it into the body.

Everything here is respiratory:

• Dyspnea on exertion, progressing to dyspnea at rest
• Orthopnea — breathless lying flat, so the patient sleeps on extra pillows
• Paroxysmal nocturnal dyspnea — waking abruptly gasping a few hours into sleep
• Bilateral crackles that do not clear with coughing
• A persistent dry cough, and in severe decompensation pink frothy sputum
• S3 gallop
• Restlessness and confusion as cerebral perfusion drops

Pink frothy sputum means alveoli are filling with fluid. That is flash pulmonary edema and it is an emergency.

Everything here is systemic congestion:

• Jugular venous distension
• Dependent peripheral edema — ankles in a walking patient, sacrum in a bedbound one
• Hepatomegaly, ascites, and right upper quadrant fullness
• Weight gain, which appears before visible swelling
• Nausea and poor appetite from gut congestion

The most common cause of right-sided failure is left-sided failure. Over time the backed-up pressure in the lungs wears out the right ventricle too.

Edema is a late sign. A patient can retain litres of fluid before you can see or press a mark into their ankle. The scale catches it days earlier.

One kilogram of weight gain equals roughly one litre of retained fluid. Weight is taken at the same time each morning, after voiding, in similar clothing, on the same scale.

Teach the patient the reporting threshold explicitly: more than 1 kg (2–3 lb) in a day, or 2.5 kg (5 lb) in a week, gets a phone call. That single habit prevents a large share of readmissions.

ACE inhibitors (-pril) reduce afterload. Watch for a persistent dry cough, hyperkalemia, and first-dose hypotension. A cough that will not settle is a common reason for switching to an ARB (-sartan).

Beta blockers (-olol) reduce workload long term but can worsen symptoms initially. Hold and reassess for bradycardia.

Loop diuretics such as furosemide pull fluid off quickly. Watch for hypokalemia, hypotension, and ototoxicity when given rapidly IV.

Digoxin strengthens contraction and slows rate. Take an apical pulse for a full minute and hold for a rate under 60. Early toxicity is easy to miss because it looks like ordinary malaise — nausea, anorexia, fatigue, and characteristically yellow-green visual halos.