EUH Morning Report: What are the Helpful Clinical Findings from the Physical Examination for Detecting Heart Failure?

The Bottom Line: “Patients with symptoms of heart failure and those with risk factors should be examined for pulmonary rales, jugular venous distention, a third heart sound, and peripheral edema and should have an ECG and chest radiograph” (Badgett)

“Very helpful findings [for detection of heart failure] are radiographic redistribution and jugular venous distention. These findings, when used alone, only help when they are abnormal and so can confirm the presence of increased filling pressure in patients with known severe systolic dysfunction. Among patients referred for consideration of cardiac transplant with a high (73%) prevalence of increased filling pressure, radiographic redistribution indicates an 80% to 90% probability and jugular venous distention, an85% to 100% probability of increased filling pressure. The absence of either finding cannot rule out increased filling pressure. In patients with lesser probabilities of increased filling pressure, such as those without known severe systolic dysfunction, isolated findings may not be useful. Somewhat helpful findings include dyspnea and abnormal vital signs. Radiographic cardiomegaly is somewhat helpful but loses its specificity after the initial detection of increased filling pressure because it can be a permanent finding and not fluctuate with changes in filling pressure. Dependent edema is helpful only when present. Edema is highly specific for increased filling pressure, although it has poor sensitivity.” (Badgett)

(Badgett)

“Patients with heart failure can have decreased exercise tolerance with dyspnea, fatigue, generalized weakness, and fluid retention, with peripheral or abdominal swelling and possibly orthopnea. Patient history and physical examination are useful to evaluate for alternative or reversible causes. Nearly all patients with heart failure have dyspnea on exertion. However, heart failure accounts for only 30 percent of the causes of dyspnea in the primary care setting. The absence of dyspnea on exertion only slightly decreases the probability of systolic heart failure, and the presence of orthopnea or paroxysmal nocturnal dyspnea has a small effect in increasing the probability of heart failure (positive likelihood ratio [LR+] = 2.2 and 2.6).” (King)

Krakow Conference: What are teaching points for JVP measurement and how to identify pulse abnormalities?

INSPECTION OF PRECORDIUM AND NECK (PG. 79)

1. One must always inspect the chest wall for pulsations at the apex or in the precordium; this is best performed in left lateral decubital position.
2. One must always inspect the right neck for presence and potential elevation of neck veins; best performed in supine position.
3. Neck vein assessment provides information that further defines and delineates a problem; in and of itself it will not lead to a diagnosis.
4. An elevated jugular venous pressure (JVP) is consistent with right ventricular dysfunction.
5. The a wave corresponds to the atrial contraction and an S4. Atrial fibrillation has no specific a waves.
6. The c wave is the most difficult to see.
7. The v wave is an excellent wave to assess the tricuspid valve.
8. Kussmaul’s sign is not specific to constrictive pericarditis. It is caused by right ventricular failure and infarction.
9. Arm forward flexion and hepatojugular reflux are both complementary tests to the standard JVP .
10. Central venous pressure (CVP) = JVP + 5. This is a more fastidious measure of neck vein height that effectively means the same as JVP.

From Cardiovascular Examination – Practice and Teaching in the Atlas of Adult Physical Diagnosis, edited by Dale Berg, and Katherine Worzala, Wolters Kluwer Health, 2005.

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TYPES OF PULSE ABNORMALITIES: 

FIG. 16.9. Pulse abnormalities.

From Blood Vessels in the Seidel’s Guide to Physical Examination, edited by Jane W. Ball, Elsevier, 2019.