Exertional dyspnea and fatigue are most often the primary complaints. Paroxysmal nocturnal dyspnea, nocturia, coughing, wheezing, right upper quadrant pain, anorexia, and nausea and vomiting also may be complaints. Although HF is generally regarded as a hemodynamic disorder, many studies have indicated that there is a poor relation between measures of cardiac performance and the symptoms produced by the disease. Patients with a very low EF may be asymptomatic (stage B), whereas patients with preserved LVEF may have severe disability (stage C). The apparent discordance between EF and the degree of functional impairment is not well understood but may be explained in part by alterations in ventricular distensibility, valvular regurgitation, pericardial restraint, cardiac rhythm, conduction abnormalities, and right ventricular function. In addition, in ambulatory patients many noncardiac factors may contribute substantially to exercise intolerance. These factors include but are not limited to changes in peripheral vascular function, skeletal muscle physiology, pulmonary dynamics, neurohumoral and reflex autonomic activity, and renal sodium handling.
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