**2.2 Advanced heart failure symptoms**

Advanced stage heart failure has been defined as a syndrome requiring the presence of at least a few of the cardinal symptoms such as shortness of breath, fluid retention/ oedema, fatigue, activity intolerance, and exercise limitations [9]. The aetiology of symptoms in heart failure is complex and difficult to understand. These symptoms are partly due to an increase in left ventricle filling pressure, partly due to a decrease in cardiac flow rate, and partly due to widespread myopathy (**Table 1**) [8].

Shortness of breath seen associated with pulmonary congestion that develops due to heart failure is the most common symptom of heart failure. Exercise dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea are among the symptoms seen in advanced heart failure in particular, and these affect physiological processes in all tissues [10]. Therefore, the grading of dyspnoea and evaluation of accompanying symptoms are important in symptom management. In addition to medical treatment in dyspnoea management, respiratory exercises are used in mild- and moderate-level dyspnoea, and positive pressure support devices are used in the management of advanced grade dyspnoea [11].


#### **Table 1.**

*Advanced stage heart failure symptoms.*

Increased activation of inflammatory cytokines creates a catabolic condition resulting in insulin resistance, anorexia, and weight loss. By causing atrophy and weakness in both skeletal and respiratory muscles, this condition further increases physical limitation. In addition, fatigue is one of the frequently seen symptoms in advanced heart failure for reasons such as electrolyte imbalance, overuse of diuretics, thyroid dysfunction, anaemia, and impairment in peripheral oxygenation as a result of a decrease in cardiac circulation and an increase in peripheral vascular resistance. The determination of effort and functional capacity and the monitoring of heart rate and heart rhythm are important in advanced stage heart failure patients [12]. Peripheral oedema seen as systemic venous congestion, abdominal ascites, and fullness in the jugular veins is among the cardinal symptoms in advanced stage heart disease patients. Follow-up of patient weight and the grading of oedema are important in respect of arranging treatment. It is recommended in the ESC 2016 guidelines that patients inform the healthcare team of an unexpected weight increase of more than 2 kg in 3 days [13].

Symptoms such as shortness of breath, lethargy, and fatigue experienced by patients with heart failure because of the nature of the disease itself, and sleep problems and a decrease in sleep quality, which is a basic component of daily living activities, occur because of the drugs used in treatment and limited functional capacity. Sleep disorders such as difficulty in falling asleep and maintaining sleep, insomnia, sleep apnoea syndrome, and excessive daytime sleepiness are frequently seen in individuals with heart failure [14]. Sleep apnoea is the most common cause of sleep disorders seen in heart failure patients. Two types of sleep apnoea are seen: obstructive, as a result of upper respiratory tract collapse, and central, as a decrease in central respiratory stimulus [15].

Comorbid problems and symptoms, especially in elderly patients with advanced heart failure, have a negative effect on the quality of life of patients and lead to frequent hospital admissions. The problems experienced cause depression, anxiety, and feelings of hopelessness in both the patient and their primary caregiver. In the management of psychological symptoms, it is recommended in the ESC 2016 guidelines that the management of self-care is included in the self-care practices of the patient and carers, and when necessary, referral to specialists should be made for mental health support.

Heart failure patients tend to have impaired cognitive functions, and this reduces their capacity to perceive when the disease is worsening and makes compliance with complex heart failure treatments more difficult.

#### **2.3 Advanced stage heart failure treatment**

Heart failure treatments include following a healthy lifestyle, drug treatments, operations, and medical support devices.

In the guidelines created by heart failure specialists, pharmacological treatments include diuretics, ACE [angiotensin-converting enzyme inhibitors]/ARB[angiotensin receptor blockers]/ARNI[angiotensin receptor-neprilysin inhibitor], Betablockers, Mineralocorticoid Receptor Antagonists [MRAs], Sodium-Glucose Co-transporter-2 inhibitors, Hydralazine and isosorbide dinitrate, and Digoxin. Regular follow-up of multiple drug use is required for the adjustment of drug doses according to present and developing symptoms [13].

In patients with advanced heart failure, compliance with the drug regimen and the development of lifestyle behaviours such as a low-sodium diet, regular exercise, and monitoring of weight together with the follow-up of drug-related symptoms that could develop are a part of the treatment [16].

When these methods are not sufficient in the treatment of advanced stage heart failure, the patients are evaluated for cardiac support devices [ventricle assistive devices] and heart transplantation.

Based on the European Cardiology Association guidelines for the diagnosis and treatment of acute and chronic heart failure, a commitment to self-care is an important component in improving patient results.
