Because the symptoms of heart failure (sometimes called congestive heart failure) can be difficult to identify and describe, it is often diagnosed quite late. If you or the person you're caring for has risk factors for heart disease, such as being a smoker or a former smoker and having high blood pressure or coronary artery disease (CAD), it's a good idea to be on the lookout for heart failure. Taken by themselves, any one of the symptoms listed here probably isn't cause for alarm, but two or more are good cause to call your doctor for an evaluation.
1. Shortness of breath, particularly when sleeping or lying down
One of the characteristic symptoms of heart failure is waking during the night or in the morning feeling as if you can't breathe deeply or can't catch your breath.
What it feels like: A feeling of compression in the chest and lungs, making it difficult to take a deep breath, particularly during exertion or when lying down. Other clues: difficulty sleeping because of breathing difficulties or choosing to sleep in a chair or recliner because it's more comfortable. This symptom is easily confused with other sleep problems and breathing problems, such as COPD and sleep apnea, but the difference is the feeling of being short of breath when lying down. Having to sit up to catch one's breath is particularly telling. Many heart failure patients compensate by propping themselves up on pillows to sleep; when making a diagnosis, doctors sometimes ask their patients how many pillows they sleep on.
Why it happens: Because the heart's ability to pump is weakened, blood backs up in the blood vessels that return blood from the lungs to the heart, causing fluid to leak into the lungs. When the head is elevated, gravity helps ease blood flow to and from the lungs, reducing the feeling of breathlessness.
2. A feeling of chest pressure or "drowning"
People diagnosed with heart failure often look back and recognize this early symptom but didn't know what was happening when they first experienced it, or had difficulty describing it.
What it feels like: It may feel like a pressure or heaviness in the chest, or a feeling akin to drowning or being compressed by a heavy weight. It may also feel as if the lungs are filled with fluid when trying to take a deep breath. Some people with heart failure experience chest pain, but not everyone does, so a lack of pain doesn't rule out heart failure.
Why it happens: Fluid overload throughout the body affects both the chest cavity and the lungs. Fluid in the lungs can feel like drowning when drawing a breath, and congestion in the chest and abdominal tissues can make the lungs feel pressure from outside, as they might deep under water.
3. Clothes and shoes that feel tight
Fluid retention with swelling is one of the primary symptoms of heart failure, but it can be difficult to recognize, since the swelling can occur in many areas of the body.
What it feels or looks like: Tightness in clothes and shoes, or puffiness of the skin. A relatively sudden increase in girth is a telltale sign of heart failure. Someone with heart failure often looks fatter or bigger around, or you might notice a protruding belly or a shirt with straining buttons that previously fit.
If the feet and ankles swell first, you may notice puffiness over the tops of the shoes or an inability to wear certain shoes that once fit. Roundness or puffiness in the face and neck is also a telltale sign. The increased weight will also show as an increase in pounds on the scale, but this may take longer to occur or to notice than the increase in size.
Why it happens: Reduced blood flow out of the heart causes blood returning to the heart to back up in the veins. The fluid then builds up within tissues, particularly in the abdomen, legs, and feet, a condition known as congestion (not to be confused with nasal congestion). Also, the weakened heart can't pump enough blood to the kidneys, which become less efficient at flushing sodium and fluids from the body.
More signs of heart failure
4. Heart-rhythm problems
It's common for people with heart failure to experience palpitations or changes in heart rhythm.
What it feels like: A fast, irregular, or pounding heartbeat. Someone with heart failure may complain that his heart is racing or that it feels like it's beating too hard. Often, a fast or irregular heartbeat is accompanied by a jittery feeling, similar to that experienced during a panic attack. Other types of arrhythmias often occur as well, including atrial fibrillation and atrial flutter. These problems can be dangerous if left untreated, so it's important to tell the doctor of any heart-rhythm problems.
Why it happens: The heart tries to make up for weakness in pumping by beating faster and harder. As it tires, the heart can't keep up a regular rhythm and skips beats, or beats with varying strength.
5. Loss of appetite
When caring for someone with heart failure, you're likely to hear, "I'm not hungry," even when you know it's time to eat. This lack of appetite may start gradually with your loved one eating smaller portions and feeling full faster, or it may come on suddenly, making you wonder if she has an upset stomach. You may also notice her eating more slowly when she does eat.
What it feels like: A sensation of being full, even when it's been a long time since a meal. You might also notice nausea, constipation, a general feeling of being sick to the stomach, or abdominal pain and tenderness. In addition, the heavy feeling in the chest and abdomen can make it unpleasant to eat. Fatigue can cause someone with heart failure to eat less simply because of fatigue; even chewing can be exhausting.
Why it happens: Fluid buildup around the liver and intestines interferes with digestion. Decreased blood flow to the stomach and intestines slows the entire digestive process, causing problems like constipation and nausea. Also, heart failure causes people to feel full quickly because of fluid retention and swelling.
6. Dizziness and light-headedness
Complaints of feeling faint, light-headed, and dizzy are among the most common problems for people with heart failure. As a caregiver, you may notice that your loved one gets dizzy when he stands up or when walking.
What it feels like: A sensation of being dizzy, faint, and light-headed, or as if "the world's spinning." Nausea or the feeling of carsickness is common, too. If these feelings are associated with palpitations or arrhythmias, it's important to call the doctor right away.
Why it happens: There are several ways heart failure causes dizziness: Inadequate oxygen in the circulatory system causes cells to become oxygen-deprived. Heart-rhythm abnormalities and narrowing in one or more valves restricts blood flow through the heart. Changing levels of chemicals in the blood, such as sodium, can cause confusion and disorientation. Standing up too quickly can cause a rapid drop in blood pressure called postural hypotension. In addition, some of the medications used to treat heart failure and other heart conditions, such as diuretics, ACE inhibitors, and beta-blockers, can cause dizziness.
This is one of the most telling yet most often missed clues to heart failure.
What it feels like: Fast, shallow breathing, racing thoughts, sweaty palms, and a rapid heart rate are all signs of a heightened anxiety response. People with heart failure often mistake these feelings for anxiety and stress; they may even refer themselves to a psychiatrist or counselor, saying they feel nervous and agitated. For many caregivers, the first clue that something's off is when a loved one informs them he's been prescribed an antianxiety medication or an antidepressant and the caregiver hasn't noticed the person experiencing psychological or mood problems.
Why it happens: Congestion around the chest and lungs causes strange sensations throughout the body that are confusing and frightening. Lack of oxygen in the bloodstream causes weakness and dizziness and may also produce disorientation and memory loss, which exacerbate anxiety. And a racing heart can feel like an anxiety attack.
More signs of heart failure
When coughing is one of the primary symptoms of heart failure, it's often confused with the flu or a cold.
What it feels like: A tickle or irritation in the lungs, or fluid in the lungs that needs to come up. The cough associated with heart failure is less likely to be felt in the throat than a flu- or cold-related cough. Sometimes the cough produces white, frothy sputum or thick mucus, which may be tinged with blood. However, heart failure can also cause a dry cough. You may notice the cough worsening when your loved one is lying down or when he first gets up.
A cough associated with heart failure will eventually become chronic, but at first it may come and go. When talking to the doctor, be sure to mention any multiple bouts of coughing you've noticed in the past year or two.
Why it happens: Fluid builds up in the lungs because the heart's pumping capacity is weakened. The fluid can cause irritation and infection and can lead to pneumonia. If your loved one complains of not being able to draw a breath because of fluid, or you hear the telltale chest rattle of pneumonia, call the doctor right away. Note that a dry cough can also be a side effect of some of the medications used to treat heart failure and other cardiac conditions.
9. Tiring easily or feeling exhausted all the time
This symptom is common to many conditions, but there are some specific clues that heart failure's the cause.
What it feels like: Being unable to catch one's breath during and after exertion. Someone with heart failure may complain of being too tired to walk somewhere or to get up and fix a meal. You might notice a cycle of sleep problems and fatigue: The person lies down, begins having the "drowning" feeling of chest congestion, and becomes anxious and unable to sleep.
Why it happens: When a weakened heart can't keep up an adequate blood supply, the body diverts blood to more vital organs such as the heart, brain, and kidneys. This deprives working muscles of oxygen, so they tire more quickly. Lack of oxygen can also cause faintness and an overall feeling of fatigue. In addition, if the kidneys aren't removing waste products as efficiently, this contributes to a feeling of exhaustion.
10. Any unexplained changes in behavior
If you're caring for someone with heart failure, you're most likely to notice the ways in which your loved one's symptoms affect her participation in day-to-day activities.
What it feels like: Changing habits or routines. Someone who's always been an enthusiastic eater suddenly says she's not hungry, or someone who's never been a napper begins sleeping less at night and more during the day. You might also notice your loved one starting to reduce her activity level in subtle ways, such as saying she's too tired to attend an event or activity that previously was important to her. Another red flag is if she starts to sleep in her chair rather than her bed. Changes in exercise and fitness are important, too, such as not wanting to walk short distances or do chores.
Why it happens: Because fluid buildup and lack of oxygen affect all bodily systems, a person with heart failure may unconsciously make changes to compensate for the discomfort without realizing she's sick. Or she may feel under the weather but believe it's temporary, and cancel appointments or decline activities accordingly.