The document discusses the clinical examination of congestion in heart failure patients. It provides details on examining symptoms, jugular vein pressure, auscultation of the heart and lungs, liver examination, and peripheral edema. Clinical signs like elevated jugular vein pressure and S3 heart sound are shown to have prognostic value. While not perfect, clinical examination is still reasonably accurate for assessing congestion and has independent prognostic information. Experience performing examinations is important.

1. az M
U
M
Congestion in Heart
Failure –
Clinical Examination
H.P. Brunner-La Rocca, MD, FESC – Prof of Cardiology
Head Heart Failure Clinic – Vice Chairman Dept. Cardiology
Maastricht University Medical Centre, The Netherlands

2. U
M
Declaration of Conflict of InterestsDeclaration of Conflict of Interests
None for this specific talkNone for this specific talk
Research grants from Roche Diagnostics, AstraZenecaResearch grants from Roche Diagnostics, AstraZeneca
Honorary from Roche Diagnostics, NovartisHonorary from Roche Diagnostics, Novartis

3. az M
U
M
Clinical examination of
congestion
oAs we have moved into the era of accelerating
advances in technology, the underpinning procedure
of all medicine, the physical examination, is at risk of
extinction. The death knell may well be the
retirement of the last generation of physicians
proficient in the bedside examination.
oIn this regard, the medical profession, with its
educational system, is its own culprit—another
example of “We have met the enemy and he is us!”
Leier et Chatterjee. CHF 2007; 13: 41

4. az M
U
M
Clinical Examination of
Congestion
oWhat do we do?
o History / symptoms
o Clinical examination
oHow accurate are we in clinically examining
congestion / heart failure?
oWhat does it tell us in addition?
oConclusion

5. az M
U
M
Clinical Examination in Heart
Failure
o Disease, which may cause heart failure? Known
CHF? Cardiovascular risk factors? Toxic?
o Diseases / circumstances, which make another
disease probable?
o Medication?
o Symptoms and signs of forward / backward failure?
o Symptoms and signs of left or right heart failure?

6. az M
U
M
Common Causes of Fluid
Overload / Decompensation
oAnaemia
oAtrial fibrillation or other arrhythmias
oSalt intake, water intake, medication mal-compliance
oFluid retention from drugs (e.g., chemotherapy, COX-
1 and 2 inhibitors, glitazones, glucocorticoids)
oHyper- or hypothyroid disease
oPulmonary causes (e.g. PAH, pulmonary embolism)
oRenal causes (e.g. renal failure, nephrotic syndrome)
oSleep apnea
oSystemic infection or septic shock
King et al. Am Fam Physician. 2012; 85: 1161

7. az M
U
M
Symptoms of Congestion
Left heart
o Dyspnoea (tachypnoea)
o Orthopnoea
o PND
o Cough
o Weight gain
Right heart
o (Dyspnoea)
o Peripheral oedema
o Weight gain
o Loss of appetite
o Abdominal swelling

8. az M
U
M
General Clinical Examination
oHeart rate: frequency / regularity?
oBlood pressure: hypertension / hypotension
oAnaemic?
oCyanotic?
oObese / cachectic?
oScars?

9. az M
U
M
Acute heart failure –
Clinical Assessment
Forrester et al. Am J Cardiol 1977; 39: 137
DryDry
ColdCold
HypovolHypovol.. ShockShock
Filling pressureFilling pressure
CardiacCardiac
performanceperformance
normalnormal elevatedelevated
normalnormal
reducedreduced
DryDry
WarmWarm
NormalNormal
WetWet
ColdCold
CardiogenicCardiogenic ShockShock
WetWet
WarmWarm
PulmPulm. Congestion. Congestion

10. az M
U
M
How to Examine Patients (with
Respect to Heart Failure)?
oCardiac impulse (left / right)
oJugular vein: 45°, externa / interna. HJR
oAuscultation of the heart:
o Heart sounds, 3rd / 4th ?
o Murmurs? Systolic versus diastolic?
oAuscultation of the longs:
o Rales / obstruction / reduced breathing?
oLiver: enlarged? Ascites?
oPeripheral oedema?

11. az M
U
M
Forward Failure
o Primarily signs of left heart failure
o Reduced cardiac function
o Hypotension
o Cold periphery, cyanosis
o Sings of reduced perfusion of different organs
(combined forward and backward failure)
o Kidneys, liver (lab findings)
o Brain
o Cachexia

12. az M
U
M
Method of examination
Jugular vein

13. az M
U
M
Differentiation of Venous Pulse
from Carotid Pulse
Venous PulseVenous Pulse Carotid PulseCarotid Pulse
More lateralMore lateral MedialMedial
Wavy, UndulantWavy, Undulant Forceful, BriskForceful, Brisk
Decrease with InspirationDecrease with Inspiration No changeNo change
Increase in supine positionIncrease in supine position No changeNo change
Increase with abdominal pressureIncrease with abdominal pressure No changeNo change
Double PeakedDouble Peaked Single PeakSingle Peak
Obliterated with PressureObliterated with Pressure Cannot be ObliteratedCannot be Obliterated
Better VisibleBetter Visible Better palpatedBetter palpated
Better viewed from foot end of bedBetter viewed from foot end of bed

14. az M
U
M
Levels of Clinical Examination in
Heart Failure Patients
oLevel 1: quick look (e.g. pt dyspnoeic with minimal
exertion?)
oLevel 2: essential heart failure examination
o General appearance, vital signs
o Jugular venous pressure, hepatojugular reflux
o Ausculation of chest and precordial
o Liver span
o Peripheral oedema, perfusion
oLevel 3: comprehensive heart failure examination
Leier et Chatterjee. CHF 2007; 13: 41

15. az M
U
M
Novel Symptom of Advanced
Heart Failure – Bendopnoea
Thibodeau et al.
JACC HF 2014; 2: 24
CardiacCardiac IndexIndex PulmPulm.. capillarycapillary wedgewedge pressurepressure RightRight atrialatrial pressurepressure
102102 patientspatients withwith HFrEFHFrEF
undergoingundergoing rightright heartheart
catheterisationcatheterisation

16. az M
U
M
Clinical Examination of
Congestion
oWhat do we do?
o History / symptoms
o Clinical examination
oHow accurate are we in clinically examining
congestion / heart failure?
oWhat does it tell us in addition?
oConclusion

17. az M
U
M
Probability of CHF
Wang et al. JAMA 2005; 294: 1944
if absentif absent
if absentif absent
if absentif absent
if presentif present
if presentif present
if presentif present
if presentif present
if absentif absent

18. az M
U
M
Probability of CHF
Wang et al. JAMA 2005; 294: 1944
if absentif absent
if absentif absent
if absentif absent
if presentif present
if presentif present
if presentif present
if presentif present
if absentif absent

19. az M
U
M
Diagnostic Accuracy of Clinical
Findings in Primary Care
NYHA
IIIOrthopnoea
NocturiaLoop
diuretic
Rales
Irreg
pulseDisplaced
apex
S3Elevated
JVPAklesw
elling
0%
20%
40%
60%
80%
100%
Sensitivity Specificity
Kelder et al. Circulation 2011; 124: 2865

20. az M
U
M
Framingham Criteria for Heart
Failure (simplified)
Major criteria
o Acute pulmonary oedema
o Cardiomegaly
o HJR
o Neck vein distention
o Orthopnoea or PND
o Rales
o Third heart sound gallop
Minor criteria
o Ankle oedema
o Dyspnoea on exertion
o Hepatomegaly
o Nocutural cough
o Pleural effusion
o Tachycardia (>120bmp)
Heart failure if two major criteria or one major and two minor are met.Heart failure if two major criteria or one major and two minor are met.
High sensitivity / NPV and medium specificity / PPVHigh sensitivity / NPV and medium specificity / PPV
Rihal et al. Am J Cardiol 1995 // King et al. Am Fam Physician 2012; 85: 1161

21. az M
U
M
Comparing Signs and Symptoms
HFrEF versus HFpEF
Bhatia et al. NEJM 2006;355:260

22. az M
U
M
Clinical Examination of
Congestion
oWhat do we do?
o History / symptoms
o Clinical examination
oHow accurate are we in clinically examining
congestion / heart failure?
oWhat does it tell us in addition?
oConclusion

23. az M
U
M
Prognostic Value of Clinical
Examination in Heart Failure
Drazner et al. N Engl J Med 2001; 345: 574
DataData fromfrom the SOLVD treatment trialthe SOLVD treatment trial
Elevated jugular venous pressureElevated jugular venous pressure
Adjusted HR=1.30, p<0.005Adjusted HR=1.30, p<0.005
Third heart soundThird heart sound
Adjusted HR=1.22, p<0.005Adjusted HR=1.22, p<0.005
AtAt thethe timetime ofof enrollmentenrollment,, investigatorsinvestigators evaluatedevaluated
patientspatients forfor thethe presencepresence oror absenceabsence ofof elevatedelevated
jugularjugular venousvenous pressurepressure andand aa thirdthird heartheart soundsound onon
the basis of athe basis of a routine physicalroutine physical examination.examination.
TheThe presencepresence ofof elevatedelevated jugularjugular venousvenous pressurepressure oror
aa thirdthird heartheart soundsound waswas indicatedindicated inin aa “yes”“yes” oror “no”“no”
format.format.

24. az M
U
M
Congestion at Discharge –
Clinically Meaningful?
Signs /
symptoms
0 1 2 3
Dyspnoea None Seldom Frequent Continuous
Orthopnoea None Seldom Frequent Continuous
Fatigue None Seldom Frequent Continuous
JVD (cm H2O) <6 6-9 10-15 >15
Rales None Bases To <50% >50%
Oedema Absent/trace slight Moderate Marked
Ambrosy et al. Eur Heart J 2013; 34: 835
WithWith higherhigher score,score, higherhigher BNP/NT-BNP/NT-proBNPproBNP,, lowerlower bloodblood pressurepressure,, lowerlower LVEF,LVEF,
lowerlower sodiumsodium,, worseworse renalrenal functionfunction,, broaderbroader QRS, moreQRS, more oftenoften previouslypreviously
hospitalisedhospitalised, more co-, more co-morbiditiesmorbidities ((renalrenal failure, diabetes, COPD, PVD)failure, diabetes, COPD, PVD)

25. az M
U
M
Congestion at Discharge –
Clinically Meaningful?
Ambrosy et al. Eur Heart J 2013; 34: 835

26. az M
U
M
How Accurate Are We in
Clinically Assessing Congestion?
o215 observations by 9 examiners in 116 consecutive
patients undergoing right heart catherisation
oProspective estimation if normal or elevated
oAdded value of BNP and echocardiography
From et al. Am J Med 2011; 124: 1051
Right sided
Left sided
90%80%70%60%50%40%30%20%10%0%
Overall Staff TraineeWhat about BNP and echocardiography?
No added value!

27. az M
U
M
Clinical Examination of
Congestion
oHistory and clinical examination are still cornerstones
in the evaluation of heart failure patients
oMuch more studies on the clinical value of
technological examinations
oNot perfect, but reasonably accurate for diagnosis of
heart failure and assessment of congestion
oIndependent prognostic value
oExperience matters  Use it for the sake of your
patients