Editing Heart failure (section)

==Signs and symptoms==
[[File:Heartfailure.jpg|thumb|upright=1.4|Signs and symptoms of severe heart failure]]
Congestive heart failure is a [[pathophysiological]] condition in which the [[cardiac output|heart's output]] is insufficient to meet the needs of the body and lungs.<ref name="NICE2010chp1" /> The term "congestive heart failure" is often used because one of the most common symptoms is [[wikt:congestion#Noun|congestion]] or fluid accumulation in the tissues and veins of the lungs or other parts of a person's body.<ref name="NICE2010chp1" />

Congestion manifests itself particularly in the form of [[edema|fluid accumulation and swelling (edema)]], in the form of [[peripheral edema]] (causing swollen limbs and feet) and [[pulmonary edema]] (causing difficulty breathing) and [[ascites]] (swollen abdomen).<ref name="Thibodeau2018">{{cite journal | vauthors = Thibodeau JT, Drazner MH | title = The Role of the Clinical Examination in Patients With Heart Failure | journal = JACC. Heart Failure | volume = 6 | issue = 7 | pages = 543–551 | date = July 2018 | pmid = 29885957 | pmc =  | doi = 10.1016/j.jchf.2018.04.005 | doi-access = free }}</ref> [[Pulse pressure]], which is the difference between the systolic ("top number") and diastolic ("bottom number") blood pressures, is often low/narrow (i.e. 25% or less of the level of the systolic) in people with heart failure, and this can be an early warning sign.<ref name="Cleveland Clinic 2021">{{cite web |url=https://my.clevelandclinic.org/health/symptoms/21629-pulse-pressure |title=Pulse pressure |author=<!--Not stated--> |date=28 July 2021 |publisher=Cleveland Clinic |access-date=10 February 2023 |quote=A narrow pulse pressure — sometimes called a low pulse pressure — is where your pulse pressure is one-fourth or less of your systolic pressure (the top number). This happens when your heart isn't pumping enough blood, which is seen in heart failure and certain heart valve diseases. |archive-date=10 February 2023 |archive-url=https://web.archive.org/web/20230210055608/https://my.clevelandclinic.org/health/symptoms/21629-pulse-pressure |url-status=live }}</ref>

Symptoms of heart failure are traditionally divided into left-sided and right-sided because the left and right ventricles supply different parts of the circulation. In biventricular heart failure, both sides of the heart are affected. Left-sided heart failure is the more common.<ref name="IQWiG2018"/>

===Left-sided failure===
The left side of the heart takes oxygen-rich blood from the lungs and pumps it to the rest of the [[circulatory system]] in the body (except for the [[pulmonary circulation]]). Failure of the left side of the heart causes blood to back up into the lungs, causing breathing difficulties and fatigue due to an insufficient supply of oxygenated blood. Common respiratory signs include [[tachypnea|increased respiratory rate]] and labored breathing (nonspecific signs of shortness of breath). [[Rales]] or crackles are heard initially in the lung bases and when severe in all [[lung fields]] indicate the development of [[pulmonary edema]] (fluid in the [[Pulmonary alveolus|alveoli]]). [[Cyanosis]], indicates [[hypoxemia|deficiency of oxygen in the blood]], is a late sign of extremely severe pulmonary edema.<ref>{{cite book | vauthors = Adeyinka A, Kondamudi NP | chapter = Cyanosis |date=2022 | chapter-url = http://www.ncbi.nlm.nih.gov/books/NBK482247/ | title = StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29489181 |access-date=2022-05-11 |archive-date=13 March 2021 |archive-url=https://web.archive.org/web/20210313021701/https://www.ncbi.nlm.nih.gov/books/NBK482247/ |url-status=live }}</ref>

Other signs of left ventricular failure include a laterally displaced [[apex beat]] (which occurs when the heart is enlarged) and a [[gallop rhythm]] (additional heart sounds), which may be heard as a sign of increased blood flow or increased intracardiac pressure. [[Heart murmur]]s may indicate the presence of valvular heart disease, either as a cause (e.g., [[aortic stenosis]]) or as a consequence (e.g., [[mitral regurgitation]]) of heart failure.<ref>{{Cite web |title=Heart Murmur: Types & Causes |url=https://my.clevelandclinic.org/health/diseases/17083-heart-murmur |access-date=2022-05-11 |website=Cleveland Clinic |archive-date=28 November 2022 |archive-url=https://web.archive.org/web/20221128033026/https://my.clevelandclinic.org/health/diseases/17083-heart-murmur |url-status=live }}</ref>

''Reverse'' insufficiency of the left ventricle causes congestion in the blood vessels of the lungs so that symptoms are predominantly respiratory. Reverse insufficiency can be divided into the failure of the left atrium, the left ventricle, or both within the left circuit. Patients will experience [[dyspnea|shortness of breath (dyspnea)]] on exertion and, in severe cases, dyspnea at rest. Increasing breathlessness while lying down, called [[orthopnea]], also occurs. It can be measured by the number of pillows required to lie comfortably, with extreme cases of orthopnea forcing the patient to sleep sitting up. Another symptom of heart failure is [[paroxysmal nocturnal dyspnea]]: a sudden nocturnal attack of severe shortness of breath, usually occurring several hours after falling asleep.<ref>{{Cite web |title=What is Exercise Intolerance? |url=https://www.webmd.com/fitness-exercise/what-to-know-about-exercise-intolerance |access-date=2022-05-11 |website=WebMD |language=en |archive-date=11 May 2022 |archive-url=https://web.archive.org/web/20220511094156/https://www.webmd.com/fitness-exercise/what-to-know-about-exercise-intolerance |url-status=live }}</ref> There may be "[[cardiac asthma]]" or [[wheezing]]. Impaired left ventricular ''forward'' function can lead to symptoms of poor systemic perfusion such as [[dizziness]], [[confusion]], and cool extremities at rest. Loss of consciousness may also occur due to loss of blood supply to the brain.<ref>{{cite web |title=Heart Failure Signs and Symptoms |url=https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure |website=heart.org |publisher=American Heart Association |access-date=16 November 2022 |archive-date=17 November 2022 |archive-url=https://web.archive.org/web/20221117045606/https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure |url-status=live }}</ref>

===Right-sided failure===
[[File:Combinpedal.jpg|thumb|upright=1.4|Severe peripheral pitting edema]]

Right-sided heart failure is often caused by [[pulmonary heart disease]] (cor pulmonale), which is typically caused by issues with [[pulmonary circulation]] such as [[pulmonary hypertension]] or [[pulmonic stenosis]]. Physical examination may reveal pitting peripheral edema, ascites, [[hepatomegaly|liver enlargement]], and [[splenomegaly|spleen enlargement]]. [[Jugular venous pressure]] is frequently assessed as a marker of fluid status, which can be accentuated by testing [[Abdominojugular test|hepatojugular reflux]]. If the right ventricular pressure is increased, a [[parasternal heave]] which causes the compensatory increase in contraction strength may be present.<ref name="ESC2016">{{cite journal | vauthors = Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P | title = 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC | journal = European Journal of Heart Failure | volume = 37 | issue = 27 | pages = 2129–2200 | date = 14 July 2016 | pmid = 27207191 | doi = 10.1093/eurheartj/ehw128 | doi-access = free | hdl = 2434/427148 | s2cid = 221675744 | url = https://academic.oup.com/eurheartj/article-pdf/37/27/2129/23748755/ehw128.pdf | type = Review | access-date = 7 February 2023 | archive-date = 7 February 2023 | archive-url = https://web.archive.org/web/20230207205925/https://academic.oup.com/eurheartj/article-pdf/37/27/2129/23748755/ehw128.pdf | url-status = live }}</ref>

''Backward'' failure of the right ventricle leads to congestion of systemic capillaries. This generates excess fluid accumulation in the body. This causes swelling under the skin ([[peripheral edema]] or [[anasarca]]) and usually affects the dependent parts of the body first, causing foot and ankle swelling in people who are standing up and [[Sacrum|sacral]] edema in people who are predominantly lying down. [[Nocturia]] (frequent night-time urination) may occur when fluid from the legs is returned to the bloodstream while lying down at night. In progressively severe cases, ascites (fluid accumulation in the abdominal cavity causing swelling) and liver enlargement may develop. Significant liver congestion may result in impaired liver function ([[congestive hepatopathy]]), jaundice, and [[coagulopathy]] (problems of decreased or increased blood clotting).<ref>{{Cite book | vauthors = Alcantara CA, Chandra A, Morvey D, von Schwarz ER |title=Right Heart Pathology |chapter=Acute Right Heart Failure |date=2018-01-03 |pages=215–225 |doi=10.1007/978-3-319-73764-5_10 |pmc=7123149|isbn=978-3-319-73763-8 }}</ref>

===Biventricular failure===
Dullness of the lung fields when [[percussion (medicine)|percussed]] and reduced breath sounds at the base of the lungs may suggest the development of a [[pleural effusion]] (fluid collection [[pleural cavity|between the lung and the chest wall]]). Though it can occur in isolated left- or right-sided heart failure, it is more common in biventricular failure because pleural veins drain into both the systemic and pulmonary venous systems. When unilateral, effusions are often right-sided.<ref name="pmid26350935">{{cite journal | vauthors = Bhatnagar R, Maskell N | title = The modern diagnosis and management of pleural effusions | journal = BMJ | volume = 351 | issue =  | pages = h4520 | date = September 2015 | pmid = 26350935 | doi = 10.1136/bmj.h4520 | hdl = 1983/deeb861e-d752-4e4c-a8d7-f00cc22eddac | s2cid = 1883969 | url = https://research-information.bris.ac.uk/en/publications/deeb861e-d752-4e4c-a8d7-f00cc22eddac | access-date = 13 February 2023 | archive-date = 9 August 2023 | archive-url = https://web.archive.org/web/20230809061730/https://research-information.bris.ac.uk/en/publications/the-modern-diagnosis-and-management-of-pleural-effusions | url-status = live | hdl-access = free }}</ref>

If a person with a failure of one ventricle lives long enough, it will tend to progress to failure of both ventricles. For example, left ventricular failure allows pulmonary edema and pulmonary hypertension to occur, which increases stress on the right ventricle. Though still harmful, right ventricular failure is not as deleterious to the left side.<ref>{{Cite book | vauthors = Sayer G, Semigran MJ |title=Heart Failure |chapter=Acute and Chronic Right Ventricular Failure |date=2017-02-22 |pages=65–84 |doi=10.1007/978-1-4471-4219-5_4 |pmc=7122716|isbn=978-1-4471-4218-8 }}</ref>