Heart failure (HF)
Heart failure (HF) is characterized by the heart's inability to pump blood effectively, leading to symptoms driven by poor circulation and fluid buildup. The most common symptoms include dyspnea (shortness of breath), fatigue, peripheral edema (swelling in the legs), and pulmonary rales (crackles in the lungs).
Of these, dyspnea is often considered a “hallmark symptom” of HF and one of the most frequent reasons for hospitalization.1 It can present in different forms:2,3
- Dyspnea on exertion – difficulty breathing with activity
- Orthopnea – shortness of breath when lying flat
- Paroxysmal nocturnal dyspnea – sudden breathlessness waking a patient from sleep
- Bendopnea – breathlessness when bending forward
HF can also present with subtle, early symptoms that may indicate worsening disease even before major fluid overload occurs:4,5
- Gastrointestinal symptoms such as nausea, vomiting, or loss of appetite
- Fatigue, often severe, can impact exercise tolerance and daily activities
- Sleep disturbances, including insomnia, frequent nighttime urination (nocturia), and sleep apnea
- Pain, an often underreported symptom, can result from deconditioning, neuropathy, or ischemic causes
Symptom variation:
Women with HF often report a higher symptom burden (e.g., fatigue, nausea, palpitations, edema, and sweating), along with higher rates of depression and anxiety.6-8
Older adults may underrecognize or underreport dyspnea, leading to delayed diagnosis. Frail older patients, however, often experience worse breathlessness alongside sleep issues and symptoms of depression.9
Valvular heart disease
Valvular heart disease (VHD) refers to any condition involving damage or dysfunction of one or more of the heart’s valves, which can lead to stenosis (narrowing), regurgitation (leakage), or both, impairing normal blood flow through the heart. It is a common cause of heart failure, with symptoms that often mirror those listed above (e.g., dyspnea, fatigue, and exercise intolerance). In many cases, VHD has a long asymptomatic period, potentially lasting years, before heart health is impacted enough for symptoms to become noticeable.10 VHD staging is based on a combination of physical exam and imaging findings, symptoms, and heart pump function.11 The most common forms in the U.S. are aortic stenosis and mitral regurgitation, each with subtle differences in symptoms and treatment approaches.12
Aortic stenosis is the narrowing of the heart’s aortic valve which reduces or blocks blood flow from the heart to the rest of the body.
Mitral regurgitation happens when the mitral valve doesn’t close properly, allowing blood to leak backward into the heart.
Excluding rheumatic heart disease — which remains prevalent in younger populations in the developing world where access to antibiotics is limited — VHD primarily affects older adults due to age-related valve calcification and degenerative changes, making it a significant contributor to HF in the elderly.13
For more information on individual VHD types, explore Eko's clinical education content.
Atrial fibrillation (AFib)
Atrial fibrillation (AFib) is the most common cardiac arrhythmia and is characterized by an irregular and often rapid heart rhythm. While palpitations, usually described as fast or irregular heartbeats, are considered classic, other common symptoms include fatigue and dyspnea. Less frequently, patients report chest pain, dizziness, and anxiety.14-16 AFib can be challenging to diagnose because symptoms don’t always align with detectable episodes of arrhythmia.17 Episodes can last anywhere from seconds to hours and often resolve before evaluation by a healthcare provider. Some patients may fluctuate between symptomatic and asymptomatic phases, even with the same “arrhythmia burden” — or percentage of time a patient lives with an abnormal rhythm. Others may remain asymptomatic or only experience nonspecific symptoms such as fatigue or dizziness, often leading to delayed recognition and treatment.
AFib presentation varies based on age and gender. Older adults are more likely to be asymptomatic or experience subtle symptoms like fatigue or breathlessness, increasing the risk of undiagnosed AFib.18 Women often report more severe symptoms, including higher rates of palpitations, fatigue, and anxiety, compared to men.
Coronary artery disease (CAD)
Coronary artery disease (CAD) is the most common form of heart disease, resulting from plaque buildup and narrowing of the coronary arteries, thus restricting blood flow to the muscles of the heart. While CAD can remain asymptomatic for years, it often presents with angina (chest pain) and other symptoms triggered by exertion or stress. Common symptoms include:19
- Chest pain or discomfort: typically a “squeezing” sensation in the chest, sometimes radiating to the jaw, shoulders, arms, or back
- Dyspnea: especially with activity
- Unusual fatigue: common but often underrecognized
- Nausea, lightheadedness, and diaphoresis (sweating)
While chest pain is considered the classic symptom, CAD symptoms can vary significantly, and not all cases present with angina. Some patients experience “silent ischemia,” where heart disease progresses without noticeable symptoms until a cardiac event (e.g., heart attack) occurs.
Women with CAD are more likely to experience atypical symptoms such as fatigue, nausea, upper back pain, and jaw pain, sometimes without classic chest discomfort.19 These differences may contribute to delayed diagnosis and treatment.
Key takeaways
Many cardiovascular diseases share overlapping symptoms. This overlap makes careful patient history-taking and a thorough physical exam essential for accurate diagnosis. Recognizing subtle differences in symptom presentation, especially those influenced by age, gender, or comorbidities, can help clinicians differentiate between conditions and ensure timely, appropriate management.
Learn how Eko can help you detect heart disease sooner.
References
1. Jurgens CY, Lee CS, Riegel B. Psychometric analysis of the heart failure somatic perception scale as a measure of patient symptom perception. J Cardiovasc Nurs. 2017;32:140–147
2. Thibodeau JT, Turer AT, Gualano SK et al. Characterization of a novel symptom of advanced heart failure: bendopnea. JACC Heart Fail. 2014;2:24–31
3. Alpert CM, Smith MA, Hummel SL, Hummel EK. Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail Rev. 2017;22:25–39
4. Valentova M, von Haehling S, Bauditz J et al. Intestinal congestion and right ventricular dysfunction: a link with appetite loss, inflammation, and cachexia in chronic heart failure. Eur Heart J. 2016;37:1684–1691
5. AbouEzzeddine OF, Wong YW, Mentz RJ et al; NHLBI Heart Failure Clinical Research Network. Evaluation of novel metrics of symptom relief in acute heart failure: the worst symptom score. J Card Fail. 2016;22:853–858
6. Haedtke CA, Moser DK, Pressler SJ et al. Influence of depression and gender on symptom burden among patients with advanced heart failure: insight from the Pain Assessment, Incidence and Nature in Heart Failure study. Heart Lung. 2019;48:201–207
7. Lam CSP, Arnott C, Beale AL et al. Sex differences in heart failure. Eur Heart J. 2019;40:3859–3868c. doi: 10.1093/eurheartj/ehz835
8. Sethares KA, Chin E. Age and gender differences in physical heart failure symptom clusters. Heart Lung. 2021;50:832–837
9. Denfeld QE, Winters-Stone K, Mudd JO, Hiatt SO, Lee CS. Identifying a relationship between physical frailty and heart failure symptoms. J Cardiovasc Nurs. 2018;33:E1–E7
10. Borer JS, Sharma A. Drug therapy for heart valve diseases. Circulation. 2015;132:1038–1045
11. Otto CM, Nishimura RA, Bonow RO et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in Circulation. 2021;143:e229]. Circulation. 2021;143:e72–e227
12. Gulati M, Levy PD, Mukherjee D et al. 2021; AHA / ACC / ASE / CHEST/ SAEM / SCCT / SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of Cardiovascular Computed Tomography. 2022 Jan-Feb;16(1):54-122
13. Gaur A, Carr F, Warriner D. Cardiogeriatrics: the current state of the art. Heart. 2024 Jun 25;110(14):933-939.
14. Lip GY, Laroche C, Ioachim PM et al. Prognosis and treatment of atrial fibrillation patients by European cardiologists: one year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot registry). Eur Heart J. 2014;35:3365–3376
15. Gleason KT, Nazarian S, Dennison Himmelfarb CR. Atrial fibrillation symptoms and sex, race, and psychological distress: a literature review. J Cardiovasc Nurs. 2018;33:137–143
16. Schnabel RB, Pecen L, Rzayeva N et al. Symptom burden of atrial fibrillation and its relation to interventions and outcome in Europe. J Am Heart Assoc. 2018;7:e007559
17. Garimella RS, Chung EH, Mounsey JP et al. Accuracy of patient perception of their prevailing rhythm: a comparative analysis of monitor data and questionnaire responses in patients with atrial fibrillation. Heart Rhythm. 2015;12:658–665
18. Siontis KC, Gersh BJ, Killian JM et al. Typical, atypical, and asymptomatic presentations of new-onset atrial fibrillation in the community: characteristics and prognostic implications. Heart Rhythm. 2016;13:1418–1424
19. DeVon HA, Burke LA, Vuckovic KM et al. Symptoms suggestive of acute coronary syndrome: when is sex important? J Cardiovasc Nursing. 2017;32:383–392
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