Congestive Heart Failure
In this JAMA Rational Clinical Exam article [1] the best historical features and patients symptoms to discriminate CHF from other causes of dyspnea are:
History of:
- Heart failure
- MI
- CAD
And symptoms of
- PND
- Orthopnea
- DOE
Physical Exam
When moving to physical exam there are exam findings assessed in chronic heart fail;ure and though when there are elevated filling pressures. We will consider those with elevated filling pressures suggesting decompensation,
For this purpose the JAMA authors rate S3 highly, but Stephen McGee’s Evidence based physical diagnosis pooled results are less impressive [2]. These S3 issues are discussed further here.
An abnormal Valsalva response is reported to have a -LR of 0.4 [1], where as in Steven McGee’s Evidence based physical diagnosis it has one of the most discriminatory operating characteristics for physical exam findings with +LR 7.6 and -LR 0.1 [2]. This maneuver is cumbersome and requires significant patient cooperation. We do not think it is practical.
Both an elevated JVP and the Abdominojugular test (AJT) are useful, with the AJT having a +LR of 8 and -LR of 0.3 [2]. More convincing is the reproducibility of AJT κ of 0.98 [2, 3].
Crackles and LE edema were reported useful by the JAMA authors [1] but are not significant with pooled results by McGee [2].
Because of its discriminatory ability and reproducibility we strongly advocate for use of the AJT, and for its poor reproducibility and performance suggest against relying on S3. Assessing the JVP is necessary for performing the AJT.
- Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294(15):1944-56.
- McGee, Steven R. Evidence based physical diagnosis. Philadelphia: Elsevier/Saunders, 2018.
- SM Butman, et al. Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension. J Am Coll Cardiol. 22(4):968-74,1993.
