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nea A more subtle and often overlooked symptom of heart failure is a chronic nonproductive cough, which is often worse in the recumbent position Nocturia due to excretion of fluid retained during the day and increased renal perfusion in the recumbent position is a common nonspecific symptom of heart failure Patients also complain of fatigue and exercise intolerance These symptoms correlate poorly with the degree of cardiac dysfunction Patients with right heart failure may experience right upper quadrant pain due to passive congestion of the liver, loss of appetite and nausea due to edema of the gut or impaired gastrointestinal perfusion, and peripheral edema Patients with acute heart failure from myocardial infarction, myocarditis, and acute valvular regurgitation due to endocarditis or other conditions usually present with pulmonary edema Patients with episodic symptoms may be having LV dysfunction due to intermittent ischemia This potentially reversible form of heart failure should be considered, especially in patients with angina pectoris and those with diabetes mellitus Patients may also present with acute exacerbations of chronic, stable heart failure Exacerbations are usually caused by alterations in therapy (or patient noncompliance), excessive salt and fluid intake, arrhythmias, excessive activity, pulmonary emboli, intercurrent infection, or progression of the underlying disease Patients with heart failure are often categorized by the NYHA classification as class I (asymptomatic), class II (symptomatic with mild activity), class III (symptomatic with moderate activity), or class IV (symptomatic at rest) However, this classification has major limitations in that patient reports are highly subjective and in that symptoms vary from day to day In any case, the classification is insufficiently sensitive to be useful in predicting outcomes or assessing the results of treatment

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pulsations may be felt in tricuspid regurgitation Sustained moderate pressure on the liver may increase jugular venous pressure (a positive hepatojugular reflux is an increase of > 1 cm) Ascites may also be present Peripheral pitting edema is a common sign in patients with right heart failure and may extend into the thighs and abdominal wall Cardinal cardiac examination signs are a parasternal lift, indicating pulmonary hypertension; an enlarged and sustained LV impulse, indicating LV dilation and hypertrophy; a diminished first heart sound, suggesting impaired contractility; and S3 gallops originating in the LV and sometimes the RV An S4 is usually present in diastolic heart failure Murmurs should be sought to exclude primary valvular disease; secondary mitral regurgitation and tricuspid regurgitation murmurs are common in patients with dilated ventricles In chronic heart failure, many of the expected signs of heart failure may be absent despite markedly abnormal cardiac function and hemodynamic measurements

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