Symptoms of heart failure

The severity of symptoms of chronic heart failure can range from minimal manifestations that occur only during physical exertion to severe dyspnea at rest. According to world literature, the number of patients with early manifestations of chronic heart failure is several times greater than the number of severely ill patients who require hospital treatment. In relation to patients with a decrease in pumping function (ejection fraction less than 40%) without obvious complaints and symptoms of chronic heart failure, a special definition is used - asymptomatic dysfunction of the left ventricle. The described condition cannot be identified with the clinical situation defined as stage I heart failure. Clinically, stage I heart failure is characterized by the fact that patients practically do not present complaints, but during physical exertion they note a slight decrease in the ejection fraction and an increase in the end-diastolic volume of the left ventricle, i.e. they reveal a deterioration in hemodynamics provoked by functional tests.

Chronic heart failure is a progressive syndrome. Patients with a latent stage of heart failure can form a group of seriously ill patients in 4-5 years, so early diagnosis and early treatment are the key to success.

Symptoms of left ventricular heart failure

One of the earliest and most characteristic signs of left ventricular heart failure is shortness of breath. At first, shortness of breath occurs only during physical exertion, fast walking, running, climbing stairs, etc. Later, it occurs at rest, increasing with a change in body position, during conversation and eating. Shortness of breath caused by heart disease increases in the horizontal position of the patient. Therefore, children with heart failure take a forced semi-sitting position (orthopnea), in which they feel relief. In this position, the heart is relieved as a result of a decrease in blood flow to its right sections, which helps to reduce pressure in the pulmonary circulation. Subjectively, shortness of breath is manifested by a feeling of lack of air. Since children themselves rarely actively present such a specific complaint, objective signs of increased breathing are considered to be tension and distension of the wings of the nose, retraction of the pliable parts of the chest due to the participation of accessory muscles in the act of breathing.

Subjective manifestations of left ventricular heart failure include rapid fatigue, increased sweating, palpitations, and decreased motor activity. Sleep disturbances may occur due to increased suffocation at night. These symptoms, like many others, such as loss of appetite, cannot be considered specific, and if children do not actively complain, early manifestations of left ventricular heart failure may be missed. A noticeable clinical sign of left ventricular heart failure is tachycardia, which occurs reflexively due to increased pressure in the left atrium and irritation of the baroreceptors in it. Pathognomonic symptoms of left ventricular failure include dry or wet cough with mucous sputum. Cough often occurs during physical exertion and at night. Hemoptysis and pulmonary hemorrhages caused by rupture of dilated bronchial veins rarely occur in children. Sometimes, as a result of compression of the recurrent nerve by an enlarged left atrium or an enlarged left pulmonary artery, hoarseness of the voice and even aphonia appear. In some cases, in children with obvious signs of congestion in the pulmonary circulation, there is not an increase in the number of respiratory movements, but dyspnea - difficulty in inhaling and prolonging exhalation - due to rigidity of the lungs. In the lungs, moist wheezing of various sizes is heard, first in the lower lateral parts of the lungs and / or mainly on the left due to compression of the left lung by the enlarged heart, and then diffusely.

A characteristic symptom of respiratory failure is cyanosis of the skin and mucous membranes. The main cause of cyanosis is an increase in the content of reduced hemoglobin in the blood of more than 50 g/l. An increase in the content of reduced hemoglobin is also demonstrated by a rich crimson-red color of the lips and fingertips. In patients with heart failure, cyanosis can be central and peripheral. Central cyanosis occurs for two main reasons:

• as a result of impaired blood oxygenation in the lungs, for example, with pulmonary artery stenosis;
• due to mixing of arterial and venous blood, for example, in some cyanotic defects (tetralogy of Fallot); central cyanosis is diffuse in nature and often does not correspond to the severity of the circulatory disorder.

Peripheral cyanosis (acrocyanosis) is associated with increased oxygen utilization by tissues and is more pronounced in parts of the body distant from the heart: on the lips, tip of the nose, terminal phalanges. The degree of acrocyanosis usually corresponds to the severity of the circulatory disorder.

In left ventricular failure, cyanosis in most patients is mixed, since along with the oxygenation disorder, oxygen utilization by tissues increases. Cyanosis that occurs in children with respiratory failure decreases or disappears with oxygen therapy, while cyanosis of circulatory origin is not eliminated.

Symptoms of Right Ventricular Heart Failure

Right ventricular failure is also characterized by subjective symptoms such as rapid fatigue, weakness, sleep disturbances, etc. Cough, shortness of breath, cyanosis are usually expressed to varying degrees and often do not correspond to the severity of congestion in the systemic circulation. They often depend on the nature of the underlying disease underlying the failure of the right sections.

Due to the weakness of the contractile function of the heart, the following changes occur.

• There is insufficient emptying of the large veins in the heart.
• The right sections (as well as the left ones) are not able to convert venous inflow into adequate cardiac output.

Due to these circumstances, venous blood accumulates in the venous system of the systemic circulation, which leads to venous plethora of the corresponding organs and to stagnation. External signs of increased venous pressure in the systemic circulation include swelling of the veins closest to the heart, especially the jugular veins. Peripheral veins are usually dilated, and their visible network is enlarged. The growing volume of circulating blood also contributes to the increasing increase in venous pressure.

Venous congestion in the systemic circulation is accompanied by an increase in the size of the liver. At first, the left lobe of the liver increases in size, then the right lobe increases as well. When determining the size of the liver in children with heart failure, its upper and lower boundaries should be determined along three lines (according to Kurlov). In terms of consistency, the liver with heart failure is soft, its surface is smooth, and the edge is rounded. It is often painful upon palpation, especially with the rapid development of right ventricular failure. When pressing on the liver area in children with significant venous congestion, swelling or increased pulsation of the jugular veins is noted (Plesh's symptom). With a significant increase in the liver, its pulsation is often determined by palpation. With chronic venous congestion, the liver becomes painless, denser, its pulsation decreases, its size decreases - "cardiac cirrhosis of the liver" develops. Clinically, liver dysfunction is detected in stage II B-III heart failure.

Changes in laboratory parameters are possible: increased bilirubin levels, dysproteinemia, increased activity of serum transaminases. Liver dysfunction may cause a worsening of the condition.

Moderate enlargement of the spleen up to 1.5 cm is found in young children.

With right ventricular failure, gastrointestinal tract disorders often occur, associated with blood stagnation in the mesenteric vessels and congestive gastritis, which can often manifest itself not only as abdominal pain, but also as intestinal motility disorders (diarrhea, constipation), and often vomiting.

Peripheral edema in heart failure is typical for older children, since babies have a fairly high hydrophilicity of tissues, and edema is latent. Peripheral edema appears more often by the end of the day. Edema begins to appear earliest on the lower extremities, especially on the feet, at the ankles, then they are found in other places, edema is located according to hydrostatic pressure, i.e. under the influence of gravity, in sloping places: in a patient lying in bed. - in the sacral region, in a patient who continues to walk or is forced to sit - on the legs. Later, edema appears in other places. The upper border of edematous tissues is horizontal. Dropsy of the cavities usually appears later than edema, less often it dominates, especially this applies to the accumulation of transudate in the abdominal cavity, which can be significant even in cases where there is no large edema (for example, with congestive and indurated liver). The transudate can fill the pleural space and pericardium, and sometimes the genitals swell significantly.

The amount of urine decreases during the day, nocturia and oliguria increase, and the extreme situation is renal block, when anuria is possible - a very serious symptom requiring emergency therapy.

Features of heart failure in newborns

The most common causes of heart failure in newborns are congenital heart defects, less often acute and congenital myocardial diseases and extracardiac pathology.

In newborns, heart failure differs in the rate of development, clinical symptoms and course, which is explained by the insufficient adaptive capabilities of the newborn, the anatomical and physiological characteristics of the organs and systems, and in general some immaturity of the functions of the organs and systems. In particular, there is a pronounced centralization of blood circulation. From the respiratory system, there may be a deficiency of the surfactant system. The progression and development of heart failure in newborns are also due to the weakness of the development of the peripheral bed and increased fragility of the capillaries. In newborns, the development of heart failure is accompanied by increased sweating associated with increased activity of the sympathetic-adrenal system. Swelling of the jugular veins is rarely detected due to the relatively short neck. Edema rarely occurs. Heart failure of stage III occurs rarely, and newborns die mainly with symptoms of heart failure of stage II.

Diagnosis of stage I heart failure is very difficult, since tachycardia and dyspnea occur in children of this age under physiological conditions, under physical and emotional stress, in particular when feeding. In stage II heart failure, the same symptoms are observed as in older children. However, signs of ventricular failure (dyspnea, tachycardia, moist rales in the lungs) prevail, in connection with which the syndrome may be underestimated and an erroneous diagnosis of pulmonary pathology, most often pneumonia, may be made. Since therapy aimed at treating pneumonia is ineffective in this situation, then after additional examination (ECG, complete X-ray examination), the cardiac cause of the disorders is identified.

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