Congestive heart failure physical examination

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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

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Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2] Edzel Lorraine Co, DMD, MD[3]

## Overview

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Physical examination is of utmost importance in the suspicion, diagnosis, and follow-up of heart failure. The focus should be targeted mainly on the evaluation of the fluid status, blood pressure, and weight changes.

## Physical Examination

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### General

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* The patient's weight should be recorded to ascertain how far they are from their "dry" weight.
* Tachycardia
* Tachypnea (an increased rate of breathing) and an increased work of breathing.
* Narrow pulse pressure (systolic blood pressure minus diastolic blood pressure is < 25 mm Hg).

### Appearance

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* The patient is often sitting upright and had labored breathing during an acute episode.

### Skin

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* The skin is cool and clammy consistent with hypoperfusion or cardiogenic shock.
* Cyanosis is observed if severe hypoxemia is present.
* Anasarca

### Neck

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* Jugular vein distention
* Central venous pressure > 16 cm H2O

### Lungs

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* Pleural effusion with dullness to percussion at the bases.
* Rales

### Abdomen

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* Hepatojugular reflux
* Hepatomegaly
* Ascites

### Heart

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* Third heart sound (S3) and a gallop rhythm.
* A displaced point of maximum impulse (PMI) consistent with an enlarged left ventricle.
* If the right ventricular pressure is increased, a parasternal heave may be present, signifying the compensatory increase in contraction strength.
* A functional holosystolic murmur of mitral regurgitation may be heard if the heart dilates excessively.
* Underlying valvular heart disease causes of congestive heart failure such as aortic stenosis.

aortic regurgitation and mitral regurgitation may be auscultated.

### Extremities

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* Bilateral ankle edema

### Neurologic

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* Confusion and altered mentation.

Signs that represent left-sided heart failure include cool clammy skin, cyanosis, rales, a gallop rhythm, and a laterally displaced PMI. Signs that represent right sided heart failure include an elevated JVP, pedal edema, ascites, hepatomegaly, a parasternal heave and hepatojugular reflux. Common signs of both left and right sided heart failure are present.

## 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [1]

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#### Clinical Assessment: History and Physical Examination (DO NOT EDIT) [1]

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Class I

"1. In patients with HF, vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications.[2][3][4][5][6][7] (Level of Evidence: B-NR) "
"2. In patients with symptomatic HF, clinical factors indicating the presence of advanced HF should be sought via the history and physical examination. [8][9][10][11][12][13] (Level of Evidence: B-NR) "
"3. In patients with cardiomyopathy, a 3-generation family history should be obtained or updated when assessing the cause of the cardiomyopathy to identify possible inherited disease. [14][15] (Level of Evidence: B-NR) "
"4. In patients presenting with HF, a thorough history and physical examination should direct diagnostic strategies to uncover specific causes that may warrant disease-specific management. [16][17] (Level of Evidence: B-NR) "
"4. In patients presenting with HF, a thorough history and physical examination should be obtained and performed to identify cardiac and noncardiac disorders, lifestyle and behavioral factors, and social determinants of health that might cause or accelerate the development or progression of HF. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]) "

### Serial Clinical Assessment of Patients Presenting With Heart Failure (DO NOT EDIT)[18][19]

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Class I

"1. Assessment should be made at each visit of the ability of a patient with heart failure to perform routine and desired activities of daily living. (Level of Evidence: C) "
"2. Assessment should be made at each visit of the volume status and weight of a patient with heart failure. (Level of Evidence: C) "

## Vote on and Suggest Revisions to the Current Guidelines

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* The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

## Sources

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* The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [18]

* 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation [19]

## References

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1. ↑ 1.0 1.1 Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
2. ↑ Ambrosy AP, Pang PS, Khan S, Konstam MA, Fonarow GC, Traver B; et al. (2013). "Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial". Eur Heart J. 34 (11): 835–43. doi:10.1093/eurheartj/ehs444. PMID 23293303.CS1 maint: Multiple names: authors list (link)
3. ↑ Selvaraj S, Claggett B, Pozzi A, McMurray JJV, Jhund PS, Packer M; et al. (2019). "Prognostic Implications of Congestion on Physical Examination Among Contemporary Patients With Heart Failure and Reduced Ejection Fraction: PARADIGM-HF". Circulation. 140 (17): 1369–1379. doi:10.1161/CIRCULATIONAHA.119.039920. PMID 31510768.CS1 maint: Multiple names: authors list (link)
4. ↑ Selvaraj S, Claggett B, Shah SJ, Anand IS, Rouleau JL, Desai AS; et al. (2019). "Utility of the Cardiovascular Physical Examination and Impact of Spironolactone in Heart Failure With Preserved Ejection Fraction". Circ Heart Fail. 12 (7): e006125. doi:10.1161/CIRCHEARTFAILURE.119.006125. PMC 6686863 Check `|pmc=` value (help). PMID 31220936.CS1 maint: Multiple names: authors list (link)
5. ↑ Caldentey G, Khairy P, Roy D, Leduc H, Talajic M, Racine N; et al. (2014). "Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: insights from the AF-CHF trial (atrial fibrillation and chronic heart failure)". JACC Heart Fail. 2 (1): 15–23. doi:10.1016/j.jchf.2013.10.004. PMID 24622114.CS1 maint: Multiple names: authors list (link)
6. ↑ Simonavičius J, Sanders van-Wijk S, Rickenbacher P, Maeder MT, Pfister O, Kaufmann BA; et al. (2019). "Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial". Am J Med. 132 (9): e679–e692. doi:10.1016/j.amjmed.2019.04.010. PMID 31051151.CS1 maint: Multiple names: authors list (link)
7. ↑ Fudim M, Parikh KS, Dunning A, DeVore AD, Mentz RJ, Schulte PJ; et al. (2018). "Relation of Volume Overload to Clinical Outcomes in Acute Heart Failure (From ASCEND-HF)". Am J Cardiol. 122 (9): 1506–1512. doi:10.1016/j.amjcard.2018.07.023. PMC 6924269 Check `|pmc=` value (help). PMID 30172362.CS1 maint: Multiple names: authors list (link)
8. ↑ Anker SD, Negassa A, Coats AJ, Afzal R, Poole-Wilson PA, Cohn JN; et al. (2003). "Prognostic importance of weight loss in chronic heart failure and the effect of treatment with angiotensin-converting-enzyme inhibitors: an observational study". Lancet. 361 (9363): 1077–83. doi:10.1016/S0140-6736(03)12892-9. PMID 12672310.CS1 maint: Multiple names: authors list (link)
9. ↑ Eshaghian S, Horwich TB, Fonarow GC (2006). "Relation of loop diuretic dose to mortality in advanced heart failure". Am J Cardiol. 97 (12): 1759–64. doi:10.1016/j.amjcard.2005.12.072. PMID 16765130.CS1 maint: Multiple names: authors list (link)
10. ↑ Gorodeski EZ, Chu EC, Reese JR, Shishehbor MH, Hsich E, Starling RC (2009). "Prognosis on chronic dobutamine or milrinone infusions for stage D heart failure". Circ Heart Fail. 2 (4): 320–4. doi:10.1161/CIRCHEARTFAILURE.108.839076. PMID 19808355.CS1 maint: Multiple names: authors list (link)
11. ↑ Kittleson M, Hurwitz S, Shah MR, Nohria A, Lewis E, Givertz M; et al. (2003). "Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality". J Am Coll Cardiol. 41 (11): 2029–35. doi:10.1016/s0735-1097(03)00417-0. PMID 12798577.CS1 maint: Multiple names: authors list (link)
12. ↑ Poole JE, Johnson GW, Hellkamp AS, Anderson J, Callans DJ, Raitt MH; et al. (2008). "Prognostic importance of defibrillator shocks in patients with heart failure". N Engl J Med. 359 (10): 1009–17. doi:10.1056/NEJMoa071098. PMC 2922510. PMID 18768944.CS1 maint: Multiple names: authors list (link)
13. ↑ Setoguchi S, Stevenson LW, Schneeweiss S (2007). "Repeated hospitalizations predict mortality in the community population with heart failure". Am Heart J. 154 (2): 260–6. doi:10.1016/j.ahj.2007.01.041. PMID 17643574.CS1 maint: Multiple names: authors list (link)
14. ↑ Marume K, Noguchi T, Tateishi E, Morita Y, Miura H, Nishimura K; et al. (2020). "Prognosis and Clinical Characteristics of Dilated Cardiomyopathy With Family History via Pedigree Analysis". Circ J. 84 (8): 1284–1293. doi:10.1253/circj.CJ-19-1176. PMID 32624524 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
15. ↑ Waddell-Smith KE, Donoghue T, Oates S, Graham A, Crawford J, Stiles MK; et al. (2016). "Inpatient detection of cardiac-inherited disease: the impact of improving family history taking". Open Heart. 3 (1): e000329. doi:10.1136/openhrt-2015-000329. PMC 4762189. PMID 26925241.CS1 maint: Multiple names: authors list (link)
16. ↑ González-López E, Gagliardi C, Dominguez F, Quarta CC, de Haro-Del Moral FJ, Milandri A; et al. (2017). "Clinical characteristics of wild-type transthyretin cardiac amyloidosis: disproving myths". Eur Heart J. 38 (24): 1895–1904. doi:10.1093/eurheartj/ehx043. PMID 28329248.CS1 maint: Multiple names: authors list (link)
17. ↑ Lousada I, Comenzo RL, Landau H, Guthrie S, Merlini G (2015). "Light Chain Amyloidosis: Patient Experience Survey from the Amyloidosis Research Consortium". Adv Ther. 32 (10): 920–8. doi:10.1007/s12325-015-0250-0. PMC 4635176. PMID 26498944.CS1 maint: Multiple names: authors list (link)
18. ↑ 18.0 18.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
19. ↑ 19.0 19.1 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967

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