Heart failure: clinical examination can help diagnose left-sided heart failure in adults.

The study

• Patients: suspected heart failure
• Intervention: clinical examination
• Outcome: diagnosis

• a raised filling pressure (12)

• systolic dysfunction (11)

• diastolic dysfunction (11)

• Reference standard: echocardiogram assessing left ventricular end diastolic pressure, pulmonary capillary wedge pressure, ejection fraction, fractional shortening
• Univariate and multivariate analysis was performed on data. Results were classified into:
  • very helpful findings- identified in two or more analyses and all positive
  • somewhat helpful- identified as positive in 50% of studies that included it
  • helpful when present- when identified specificity >90% (SpPin)

The evidence

• findings very helpful: increased filling pressure:
  • radiographic distribution
  • raised JVP
  ejection fraction <40%:
  • radiographic cardiomegaly or redistribution
  • anterior q waves
  • left bundle branch block
  • abnormal apical impulse
  diastolic dysfunction:
  • current hypertension (systolic >160, diastolic >100)
• findings somewhat helpful: increased filling pressure:
  • dyspnoea
  • orthopnoea
  • tachycardia
  • decrease systolic blood pressure
  • proportional pulse pressure <25%
  • third heart sound
  • abnormal abdominojugular reflex
  • radiographic cardiomegaly
  ejection fraction <40%:
  • pulse >90
  • systolic blood pressure <90 mmHg
  • proportional pulse pressure <33%
  • third heart sound
  • crackles
  • dyspnoea
  • prior MI
  • CK >200 in post-infarct patient
  diastolic dysfunction:
  • obesity
  • no tachycardia
  • elderly
  • non-smoker
  • no coronary artery disease
• findings helpful when positive: increased filling pressure:
  • oedema
  ejection fraction <40%:
  • raised JVP
  • oedema
  diastolic dysfunction:
  • normal radiographic heart size
• Notes on above:
  • radiographic cardiomegaly for ejection fraction and current hypertension for diastolic dysfunction are independent variables
  • proportional pulse pressure (systolic- diastolic/systolic)
  • apical impulse: sustained impulse important- detect using simultaneous auscultation and palpation; impulse must be at least two thirds of systole to be called sustained. Use a tongue blade pressed over apex to produce a visual demonstration of the impulse (or S3). Any increase in size can be detected by percussion.
  • pulmonary vessels redistribution- upper lobe vessels larger than lower (at position equidistant above and below hilum)
• K interobserver:
  • overall: 0.28-0.37
  • JVP: 0.31-0.69
  • displaced apex beat: 0.53-0.73
  • cardiomegaly: 0.48
  • S3: 0.14-0.60
  • rales: 0.12-0.65
  • oedema: 0.27-0.64
  • interstitial oedema: 0.56-0.83
  • redistribution: 0.38-0.50
• raised systolic filling pressure:
  • known severe diastolic function?- no (20%); yes (75%)
  • no with 1 or less finding (<10%); no with 2 findings (~70%); no with 3 or more findings (>90%)
  • yes with 0 findings (<10%); yes with 1 or more finding (>90%)
• Not useful in diagnosis:
  • decreased ejection fraction- age, orthopnoea, LVH on ECG, history of HT, history of CCF
  • diastolic dysfunction- LVF on ECG, history of hypertension, sex, presence of third or fourth heart sound

Comments

1. There is usually not enough evidence to diagnose diastolic dysfunction- all patients with a raised filling pressure need objective ejection fraction assessment. Differential diagnosis, valvular heart disease, right ventricular dysfunction from emphysema or pulmonary fibrosis, intermittent LV ischaemia, iatrogenic volume overload.
2. Chest x-ray: radiographic cardiomegaly correlates with total LV size (remember other causes, eg. hypertrophy!). False positives include:
   • apical fat pad
   • transverse position of heart
   • decrease in thoracic width
   • AP film, poor inspiration
3. In general, isolated findings are not good enough to make a diagnosis.
4. The diagnosis of heart failure improves as clinicians become more experienced.

Citation

1. Badgett RG, Lucey CR, Mulrow CD: Can the clinical examination diagnose left-sided heart failure in adults?. Journal of the American Medical Association 1997; 277 (21): 1712-1719

Patient	heart failure
Intervention or Exposure	clinical signs
Outcome	diagnosis