Congestive heart failure physical examination

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Congestive Heart Failure Microchapters


Patient Information


Historical Perspective



Systolic Dysfunction
Diastolic Dysfunction


Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors


Natural History, Complications and Prognosis


Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings


Chest X Ray

Cardiac MRI


Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies


Invasive Hemodynamic Monitoring

Medical Therapy:

Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Positive Inotropics
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

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:

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

Congestive heart failure physical examination On the Web

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Ongoing Trials at Clinical

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FDA on Congestive heart failure physical examination

CDC on Congestive heart failure physical examination

Congestive heart failure physical examination in the news

Blogs on Congestive heart failure physical examination

Directions to Hospitals Treating Congestive heart failure physical examination

Risk calculators and risk factors for Congestive heart failure physical examination

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]


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



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






aortic regurgitation and mitral regurgitation may be auscultated.



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]

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

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]

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



  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).
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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).
  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.
  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.
  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.
  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
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