The results of our study in residents of a large central New England metropolitan area provide insights to the clinical symptoms associated with decompensated HF and the relation of these signs and symptoms to patients' demographic and clinical characteristics, treatment practices, and short-term outcomes. Our results suggest that many patients with HF present with multiple acute signs and symptoms, and the vast majority present with breathlessness and signs of congestion, and not those indicative of low cardiac output. That said, approximately 40% of patients reported 2 or fewer common symptoms of HF. Patients reporting fewer HF related symptoms were older and more likely to be female, less likely to have serious accompanying comorbidities, and were less likely to be treated with effective cardiac therapies. Symptom presentation was similar for patients with an initial or previously documented episode of HF and whether we examined the 5 most common symptoms reported by patients or all 14 of the acute signs and symptoms examined.
The profile of different symptoms, extent of delay in seeking medical care, and relation of acute symptoms to medical treatment and hospital outcomes in hospitalized patients with decompensated HF has not been examined in detail in the published literature. In prior studies based on the review of information contained in hospital medical records, which was similar to the approach utilized in the present investigation, the frequency and type of symptoms reported by patients with acute HF were similar to those observed in our population-based investigation [6
]. For example, in a study based on the review of the medical records of 753 patients with HF who were hospitalized at a Veteran's Administration hospital, the most common symptoms reported by patients at the time of hospital admission were dyspnea, edema, and fatigue [7
Heart failure is typically associated with multiple clinical signs and symptoms that can interact thereby affecting a patients' perception of some or all of these acute symptoms. The intensity, timing, level of distress, and quality of symptoms, as well as mismatch between the symptoms expected and those actually experienced, may each affect a patient's perception of, and responses to, their acute symptomatology [11
]. Psychologic as well as situational factors may also influence the acute symptom experience and its interpretation. In our study, we found that patients' reporting of symptoms may also impact how they are treated once they seek medical attention.
Patients who reported fewer symptoms of acute HF were less likely to be treated with effective treatment regimens and use of different nonpharmacologic regimens. In addition, in both crude and multivariable adjusted analyses, our findings suggest that patients with fewer signs and symptoms of decompensated HF, particularly those related to the 5 most commonly reported symptoms, are at greater risk for dying during their acute hospitalization as well as during the first month of their hospital admission. It needs to be noted, however, and despite the nonrandomized nature of the present study which places appropriate caveats on the interpretation of our findings, that after adjustment for the receipt of various hospital treatment practices, the association between hospital and 30 day death rates became increasingly attenuated (especially for the 5 most commonly reported acute symptoms). These findings suggest that the failure to treat these patients with effective cardiac medications may lead to increased short-term death rates in this relatively under-recognized (e.g., fewer acute symptoms) patient population.
Numerous hypotheses can be offered for our observed findings. It is possible that patients reporting fewer acute symptoms may have experienced longer delays to hospital presentation, more atypical presentation, and more diagnostic uncertainty leading to possible delays in appropriate treatment and higher death rates. The observed differences in hospital treatment practices based on the number of symptoms reported by patients suggest that healthcare providers respond differently based on patients' symptom profile. It is also possible that the reporting of fewer symptoms is a marker for patients with more severe comorbidities, or even impaired cognition, that may impact subsequent survival. Further studies need to be carried out to understand the reasons for these observed associations including a more detailed assessment of the frequency, intensity, and duration of patient's symptoms and actions taken to seek acute medical care.
Study Strengths and Limitations
The strengths of the present study are the inclusion of all hospitalized patients with decompensated HF from a large New England metropolitan area, use of standardized criteria for confirmation of the diagnosis of HF, and inclusion of a wide variety of possible symptoms of HF. The limitations of this study include the reliance of information contained in hospital medical records and inability to separate the chief symptom complaint from more ancillary symptoms. Our study also does not necessarily confirm the absence of selected symptoms of acute HF, but merely the absence of documentation of the various symptoms examined. Due to the large amount of missing data on ejection fraction, we were unable to further classify patients into those with systolic from those with diastolic HF. Factors such as socioeconomic status, noncardiac disabilities, usual activity levels, prior treatment history, cognitive function, and a history of depression were unable to be examined in the present study. Our study sample was primarily Caucasian and the present findings may not apply to patients of other race/ethnicities.