Patients may not verbalize common and atypical signs and symptoms of heart failure and may not understand their association with worsening disease and treatments.


To examine prevalence of signs and symptoms relative to demographics, care setting, and functional class.


A convenience sample of 276 patients (164 ambulatory, 112 hospitalized) with systolic heart failure completed a 1-page checklist of signs and symptoms experienced in the preceding 7 days (ambulatory) or in the 7 days before hospitalization. Demographic and medical history data were collected.


Mean age was 61.6 (SD, 14.8) years, 65% were male, 58% were white, and 45% had ischemic cardiomyopathy. Hospitalized patients reported more sudden weight gain, weight loss, severe cough, low/orthostatic blood pressure, profound fatigue, decreased exercise, restlessness/confusion, irregular pulse, and palpitations (all P < .05). Patients in functional class IV reported more atypical signs and symptoms of heart failure (severe cough, nausea/vomiting, diarrhea or loss of appetite, and restlessness, confusion, or fainting, all P ≤ .001). Sudden weight gain increased from 5% in functional class I to 37.5% in functional class IV (P < .001). Dyspnea occurred in all functional classes (98%–100%) and both settings (92%–100%). Profound fatigue was associated with worsening functional class (P < .001) and hospital setting (P = .001); paroxysmal nocturnal dyspnea was associated with functional class IV (P = .02) and hospital setting (P < .001).


Profound fatigue is more reliable than dyspnea as an indicator of functional class. Nurses must recognize atypical signs and symptoms of worsening functional class to determine clinical status and facilitate patient care decisions.

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