General physical examination he overall physical examination may be normal, especially in well-nourished patients with heart failure of recent onset. Severe heart failure, on the other hand, is associated with pallor, peripheral cyanosis (nail bed, nose), clammy palms, low body temperature (peripheral vasoconstriction), muscle atrophy, weight loss, and possible jaundice (especially of the conjunctivae). In end-stage heart failure, the respiratory rate may be increased at rest or after a change in posture (rising from a sitting position, undressing for examination).
In some cases, careful inspection may offer important clues as to etiology and pathophysiology. Lack of facial expression, a thick tongue, and dry hair suggest hypothyroidism. Bronze pigmentation indicates hemochromatosis. Pallor signals anemia. Thin muscles and large calves reflect myopathy. Xanthomata point to coronary heart disease, warm skin and hyperthermia to infection, and agitation, sweating, and protruding eyes to hyperthyroidism.
Cardiac physical examination
An enlarged apex beat, or point of maximal impulse (PMI), palpated when the patient leans forward in the left lateral position, suggests an enlarged left ventricle. A third heart sound indicates major left ventricular dysfunction and increased atrial pressure due to increased chamber stiffness. Gallop rhythm is a highly specific sign, but has low sensitivity and high intraobserver variability. It has independent prognostic significance. Cardiac murmurs may be barely audible in low cardiac output or tachycardia. The latter indicates sympathetic activation or ongoing arrhythmia. In heart failure, a low cardiac output lowers systolic blood pressure and pulse pressure, and produces barely palpable peripheral pulses. Hypertension is not necessarily a bad sign, because it reflects a measure of cardiac reserve and makes treatment easier. It is important to check for postural changes in blood pressure to prevent the dizziness and syncope that may be exacerbated by common heart failure medications.
Pulsus altemans (regular but with variable amplitude) is easier to evaluate when the patient is standing and holding his/her breath in mid-expiration. It is defined by alternation in systolic pressure exceeding 20 mm Hg.
Pulsus paradoxus is when systolic blood pressure falls by more than 20 mm Hg during inspiration. It is rare in heart failure, but common in constrictive pericarditis. An irregular pulse indicates arrhythmia.
Ankle edema is the most common sign of fluid retention, typically increasing over the course of the day, from mild in the morning to severe in the evening. Pitting edema can be demonstrated by pressing on the skin firmly for 30 seconds. Chronic edema of the extremities causes cutaneous and subcutaneous changes such as reddening and hyperpigmentation. The skin becomes appears indurated and uneven, and tends to desquamate. In severer chronic cases, ascites may develop, especially in the presence of severe tricuspid insufficiency or constrictive pericarditis. Pleural effusion secondary to heart failure is more common on the right. Even if bilateral, it is generally more prominent on the right. Pericardial effusion is rarely significant.
Water retention and high venous pressure cause not only pulmonary edema (mid-inspiratory or end inspiratory rales usually audible at the pulmonary bases), but also hepatic edema (tender liver enlargement due to capsule distension, diffuse abdominal pain). Tricuspid regurgitation secondary to right ventricular hypertrophy may cause hepatic pulsation.
The jugular veins provide an index of venous pressure with the patient reclining at 45°. The venous pulse differs from the arterial pulse in being larger, more diffuse, biphasic, and impalpable. It disappears when external pressure is applied at the base of the chin, changes with respiration (decreasing with inspiration) and posture, and rises with abdominal compression. Jugular venous pressure is measured by the vertical distance in cm between the superior border of the jugular pulsation and the angle of Louis (sternal angle), a reference point located approximately 5 cm from the right atrium. The upper normal value is 3 cm, equivalent to a venous pressure of 9 cm H20. Higher values denote raised venous pressure.
Inspection of the pulse provides further information. A prominent presystolic a wave, timed with atrial systole, suggests right ventricular dysfunction. A prominent 2 wave, timed with ventricular systole, indicates tricuspid insufficiency. A prominent y downslope, associated with Kussmaul’s sign (paradoxical jugular distension with inspiration), suggests pericardial constriction, right ventricular dysfunction or restrictive cardiomyopathy. Increased venous pressure is an independent adverse prognostic indicator.
Hepatojugular reflux is elicited by abdominal compression. The patient must be relaxed, breathing normally, and aware that the maneuver is being performed. Firm constant pressure is applied to the mid abdomen for 15 to 30 seconds, while observing the top of the jugular column. The test is negative if the
increase is <3 cm, or >3 cm but transient, or if it fails to rise in the first 10 seconds. A positive test (>4 cm) implies hepatic and abdominal congestion.
A simple congestion scoring system has been proposed (Table).
Jugular vein distension
Weekly weight gain (2 to 3 kg)
Diuretic dose adjustment required since previous appointment
Table. Congestion score criteria (no criteria: no congestion; 1-2 criteria: minor congestion; 3-5 criteria: major congestion).
Clinical probability of increased left ventricular filling pressures
Isolated clinical signs have a limited ability to detect increased left ventricular filling pressures. A recent metaanalysis identified raised jugular venous pressure and radiographic pulmonary flow redistribution as the strongest predictors. Other useful predictors are congestive symptoms, tachycardia, reduced systolic blood pressure and pulse pressure, a third heart sound, rales, and hepatojugular reflux. Cardiomegaly may be useful in the initial stages, but lacks specificity at later stages by remaining unchanged even when end-diastolic pressure decreases. Edema is another useful indicator, with 90% specificity. Patients with known left ventricular dysfunction can be subgrouped using combinations of these indicators: >3 indicators = high (90%) probability of increased left ventricular filling pressures; 1 to 3 indicators = intermediate probability; 0 indicators = low (^10%) probability.
sign; symptom; diagnosis; physical examination; congestion; left ventricular filling pressure
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