**3. The prevalence of risk factors of heart failure among patients in outpatient practice**

An analysis of a sample of 3,000 outpatient visitors found that the prevalence of obesity among adult outpatient patients is 20% (95% CI: 18.6–21.4%). Obesity increased the likelihood of shortness of breath in men and women almost equally (the relative risk was 2.39 and 2.49, respectively). The prevalence of diabetes mellitus, according to the survey, among adult outpatient visitors is 5.9%. The prevalence of smoking and alcohol abuse among adult outpatient visitors is 35% and 12.4%, respectively. The prevalence of MI among adult outpatient patients is 4.7%. According to the survey, the prevalence of hypertension among adult outpatient visitors was 37.9%.

Hence, among the risk factors, arterial hypertension has the greatest population contribution to the development of HF. It was found that not only the presence and severity of arterial hypertension affected the development of HF, but also the duration of increased blood pressure. Thus, in patients with confirmed HF, dyspnea developed on average only 8.4 years after the onset of hypertension, and in patients with excluded HF, dyspnea occurred only 2.8 years later. That is, when assessing the probability of a connection between the appearance of shortness of breath, the exposure to hypertension should be taken into account.

### **4. The clinical diagnosis of heart failure**

The diagnosis of chronic HF begins, of course, with the patient's complaints. Thanks to the existing complaints of the patient that he comes into our field of vision. However, the complaints are not specific. If the patient has a complex of

#### *Features of Diagnostics and Differential Diagnostics of Chronic Heart Failure in Outpatient… DOI: http://dx.doi.org/10.5772/intechopen.95863*

manifestations of heart failure such as oedema, orthopnea, complaints of dyspnea, heaviness in the right hypochondrium, fatigue, then we will not be difficult to diagnose HF. But if we consider each of the signs of heart failure separately, it turns out that their specificity is quite low. And just such a situation is observed in the initial manifestations of heart failure. These patients, who have 1–2 manifestations, are the cornerstone of the diagnosis of initial forms of heart failure.

The most common manifestation of chronic heart failure is a complaint of shortness of breath. The sensitivity of this sign is close to 100%, but the specificity is only 17% [6]. When dyspnea is difficult for the patient to inhale, it has mostly inspiratory character. The shortness of breath is quite stereotypical. It cannot be there for a while, then disappear and reappear spontaneously. Without a treatment it constantly progresses as a rule. In patients with limited mobility, dyspnea may not appear during exercise, but may debut at night in a horizontal position. Short-acting nitrates and diuretics can have a good effect on dyspnea of cardiac origin. The dyspnea increases as the intensity of the cause increases. For example, an increase of blood pressure or the appearance of paroxysms of atrial fibrillation or onset of angina pectoris usually cause an increase in dyspnea. When shortness of breath increases, a cough is added, first dry, then with foamy sputum and blood. This may occur during a period of inadequate physical activity of the patient. If shortness of breath manifests at rest, then there is more accurate sign of heart failure: shortness of breath becomes heavier in a horizontal position and is relieved when the head end of the trunk is raised. The patient's forced sitting position is called orthopnea. The analysis of these features of dyspnea allows for more accurate diagnosis of heart failure.

Bendopnea, described in recent years [7], is the occurrence of shortness of breath after bending the patient sitting in a chair and pressing the abdominal belt. Shortness of breath in a patient with CHF persists for at least 30 seconds. However, this sign is not specific enough and can be observed in lung diseases and obesity [8].

Another sign of heart failure is rapid fatigue during physical activity and longer recovery after exercise. Fatigue is observed in about 85% of patients with HF [9]. The appearance of this symptom is associated with a violation of nutrition and structural adjustment of muscle tissue in patients, but may be due to hypovolemia and hypokalemia due to the use of diuretics. The specificity of the sign is extremely low, but good performance quite accurately indicates the absence of heart failure in the patient. Weakness in heart failure cannot be reduced by short-term training. In the initial stages of the disease, the patient does not feel weak at rest. It occurs only during physical activity. The patient is able to withstand short-term quite intense physical activity and at the same time gets very tired with low-intensity, but prolonged exercise. But even with these features, fatigue is a low-specific sign of heart failure.

The appearance of heaviness in the right hypochondrium indicates an increase in the liver due to stagnation in the large circle of blood circulation. The widespread pathology of the gallbladder makes this clinical sign very non-specific.

Oedema in patients with heart failure starts from the lower part of the legs and gradually involves the upper parts. In bedridden patients, edema forms on the sacrum. Oedema has a dense consistency. Their prolonged existence leads to hyperpigmentation of the skin and trophic changes in the area of oedema.

The patient's complaints must be coordinated with the physical examination data. Low exercise tolerance should correlate with the appearance of signs of congestion. The process of congestion, as a rule, from the beginning involves a small circle of blood, and for a long time during auscultation of the lungs we do not find wheezing. As a rule, wheezing in the lungs appears when the patient has shortness of breath at rest or with minimal physical activity. With long-term heart failure, a patient with wheezing lungs may not have shortness of breath at rest. Wheezing

appears from the lower parts of the lungs. They are moist, small-bubbly, in the beginning not sound, but with the appearance of fibrosis of the lungs they become resounding and do not respond to treatment with diuretics.

The formation of congestion in a large circle of blood circulation is manifested by an increase and soreness of the liver. When pressing on the liver during deep breathing of the patient, you can see an increase in blood filling of the neck veins by >3 cm sustained during 10 s (hepatojugular reflux), with an abrupt fall after the pressure is released [10]. This proves the connection between an enlarged liver and increased pressure in the veins of the large circle of blood. The appearance of tricuspid insufficiency is accompanied by the occurrence of pulsation of the neck veins. Due to the decline in the contractility of the right ventricle, the patient has a decrease in shortness of breath, but an increase in weakness.

Oedema of the lower extremities sometimes precedes the appearance of hepatomegaly, but it also happens the other way around. This depends only on the innate predisposition to leg swelling and also from the patient's position. Oedema is dense in consistency, appearing first in the lower areas, then rising to the top. With longterm oedema in the area of their localization, skin atrophy occurs, hyperpigmentation appears, and the skin becomes easily vulnerable.

The third heart tone occurs when the pressure of filling the left ventricle in the diastole is increased. Listening to the third heart tone is specific for heart failure, but it is extremely rare among outpatients.

If there is a suspicion of heart failure in the patient, you need to go upstream. In other words, it is necessary to determine the probability of developing heart failure in the patient. When communicating with the patient, you need to pay attention to the coincidence of manifestations of heart disease and possible manifestations of heart failure. In addition, it is important to determine the dependence of manifestations on heart disease. Frequent provocateurs of heart failure are uncontrolled arterial hypertension, paroxysms of fibrillation or atrial flutter, the development of acute coronary syndrome, alcohol abuse, sodium or fluid overload and the addition of infection.

To sum up, it should be noted that the accuracy of the diagnosis of HF based on clinical manifestations and physical examination data depends on the number of detected signs and symptoms, as well as on the chronological relationship with the cause of occurrence. Data analysis requires the use of clinical thinking.
