Highlights of the physical examination in heart failure

Because decompensated heart failure (HF) patients present primarily with symptoms of congestion, the assessment of volume status is of paramount importance. Despite the addition of new technologies that can predict intracardiac filling pressures, the physical exam (PE) remains the most accessible and cost-effective tool available to clinicians. An elevated jugular venous pressure (JVP) is considered the most sensitive sign of volume overload, although the commonly used 'method of Lewis' has several limitations. A useful cutoff is that if the JVP is greater than 3 cm in vertical distance above the sternal angle, the central venous pressure is elevated. In addition to assessment of volume status, the PE in HF can reveal adverse prognostic signs, namely: elevated JVP, presence of third heart sound, elevated heart rate, low systolic BP, and low proportional pulse pressure (< 25%). This article will review the evidence for the diagnostic and prognostic utility of common PE findings in HF.