There is a wide spectrum of potential clinical presentations with heart failure. Most patients have signs and symptoms of pulmonary congestion including dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.

Symptoms

Dyspnoea

Breathlessness or dyspnoea is a cardinal symptom of left ventricular failure and the patient may present with exertional dyspnoea or orthopnoea or paroxysmal nocturnal dyspnoea or acute pulmonary edema.  

Exertional Dyspnoea

Degree of physical activity goes on decreasing as the heart failure progresses. Orthopnoea is dyspnoea that develops in recumbent position and is relieved by sitting up. It develops within few minutes of assuming recumbency and occurs when the patient is awake. Decreased pooling of fluid in the lower limbs and shift of fluid to the intrathoracic compartment resulting in increased preload causes orthopnoea.

Paroxysmal Nocturnal Dyspnoea

 Here the patient, after going to sleep for sometime, suddenly gets up with dyspnoea and suffocation and sits upright gasping for breath. Bronchospasm may be present and hence is often referred to as cardiac asthma. With patient asleep at night, the increased resorption of fluid into the vascular space, increased intrathoracic volume, elevation of diaphragms due to recumbency, reduced sympathetic support during night and nocturnal depression of respiratory center during night are the factors operative producing paroxysmal nocturnal dyspnoea.