Full spectrum of symptoms associated with heart failure: a mixed-method systematic review and narrative synthesis
Authors: Seckin M , Johnston B , Stewart S , Petrie M 
Published: July 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background & aim
People living with heart failure (HF) experience a variety of symptoms. Although assessing and monitoring the full range of symptoms they experience (in order to monitor/prevent progressively worse HF and thereby improve quality-of-life), clinical guidelines mostly focus on symptoms related to congestion (basically for short-term before/after hospitalisations). Thus, the full range of symptoms experienced in HF settings is under-appreciated. This review aimed to investigate the full spectrum of symptoms associated with HF as reflected by European Society of Cardiology (ESC)’s HF guidelines list of "typical" versus "less typical" symptoms, plus those not on the list, on an age- and sex-specific basis.

Methods
A mixed-method systematic review (MMSR) and narrative synthesis were conducted using six electronic database searches. Joanna Briggs Institute (JBI) Methodology for MMSR was used as a framework. Symptoms were grouped into; 1)ESC-listed typical, 2)ESC-listed less typical and 3)Non-ESC-listed symptoms. Differences in the pattern of HF-related symptoms were then investigated from the following perspectives; A)Hospital versus community settings, B)Age of individual &lt;65 years versus ≥65 years and C)Men versus women.

Results
37 papers (26 quantitative, 8 qualitative and 3 mixed-method research) were included (Figure 1). 36 studies reported at least one of 6 ESC typical, and 35 studies at least one less typical ESC symptom (n=10). Some of the "less typical symptoms" were rarely reported (such as wheezing and bendopnea). 37 non-ESC symptoms were also identified. These were documented in 35 of 37 studies. Some non-ESC symptoms were commonly reported [for example, chest pain/discomfort (21/37), difficulty sleeping (21/37), nausea/vomiting/indigestion (20/37)]. Most observed symptoms of each group were: breathlessness (typical-78%,n=3659); cough (less typical-48%,n=3450); and lack of energy (non-ESC-69%,n=1758). Cough, palpitations and dizziness were reported more in community than hospital studies whereas wheezing was reported more in hospital settings. Typical symptoms (orthopnoea/paroxysmal nocturnal dyspnoea/swelling) were more often reported in cohorts ≥65 (than &lt;65) years of age. Due to the paucity of women in studies, there was little information available to compare symptoms of men and women.

Conclusion
As expected, there is a diverse range of symptoms experienced by people with HF. However, these data reveal many of these symptoms are not listed by ESC in their HF guidelines (either as a typical/less-typical symptom). There is a danger that full range (and impact/clinical importance) of these symptoms are disregarded by clinicians. Current clinical management guidelines should, therefore, more fully consider the full spectrum of symptoms experienced by those affected in different phases of their journey with HF. Furthermore, more research is needed to explore sex-specific differences in this regard. PROSPERO ID:CRD42020185786.Figure 1: Graphical abstract