Heart Failure (Cardiac Insufficiency): Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

• General physical examination – including blood pressure, pulse, body weight, height (determination of body mass index/body mass index); further:
  • Inspection (viewing).
    • Elevated jugular vein pressure/neck vein congestion? (Jugular venous congestion (JVD) or increased jugular venous pressure (JVP) is a sign of increased right ventricular filling pressure. )Note: To evaluate for JVD, the patient should first be examined in an upright sitting position; then in various upper body positions (eg, supine, at 30° to 45°, sitting, or standing); tangential illumination of the jugular veins with a lamp is helpful to better visualize pulsation [Caveat (Warning)!
      • Neck vein congestion may be absent in acute heart failure (esp. with therapy); if present, highly predictive
      • Paradoxical increase in jugular venous congestion during inspiration (= Kußmaul sign) is a predictor of poor survival in heart failure and especially after heart transplantation]

      Hepatojugular reflux (HJR): reliably indicates increased pulmonary capillary constriction pressure (wedge pressure, PCWP)Positive HJR: when the jugular vein remains congested (JVP 3 cm) for the entire time during a 10-second abdominal pressurization, and JVP abruptly decreases thereafter [Positive HJR is associated with poorer prognosis]

    • Peripheral edema (praetibial edema?/water retention in the area of the lower leg/before the tibia, ankle; in supine patients: presacral/before the sacrum).
    • Generalized peripheral cyanosis [blue discoloration of lips and acral (finger/toe extremities, nose, ears].
    • Central cyanosis [bluish discoloration of skin and central mucous membranes, e.g., tongue]
  • Examination of the heart, it may be possible to determine:
    • Displaced (and widened) cardiac apex thrust (HSS; palpable bumping of the cardiac apex against the anterior chest wall during systole/contraction of the heart; placing the palm of the hand on the left parasternal side facilitates finding the cardiac apex thrust; this is assessed with two fingers: Location, extent, and strength).
    • Auscultation findings: present 3rd heart sound (time: early diastole (relaxation and filling phase of the heart); approx. 0.15 sec. after the 2nd heart sound; due to the impingement of the blood jet on the stiff wall of the (insufficient) ventricle/heart chamber); highly specific, but not very sensitive
    • Tachycardia (heartbeat too fast: > 100 beats per minute).
  • Examination of the lungs
    • Auscultation (listening) of the lungs [rales (RGs)? DD pneumonia (lung inflammation)]
    • Percussion (tapping) of the lungs [pleural effusion: muffled; Notice! Pleural effusions are more common on the right side because the pleural area is larger on that side].
  • Abdominal (stomach) examination [hepatomegaly? (liver enlargement)/congestive liver); splenomegaly? (splenomegaly)/secondary to portal hypertension/pulmonary hypertension]
    • Auscultation (listening) of abdomen [vascular or stenotic sounds?, bowel sounds?]
    • Percussion (tapping) of the abdomen.
      • Meteorism (flatulence): hypersonoric tapping sound.
      • Attenuation of tapping sound due to enlarged liver or spleen, tumor, urinary retention?
      • Hepatomegaly (liver enlargement) and/or splenomegaly (spleen enlargement): estimate liver and spleen size.
    • Palpation (palpation) of the abdomen (abdomen) (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, renal bearing knocking pain?).
• 6-Minute Walk Test – standardized procedure for objective assessment, determination of severity, and progression of exercise limitation attributable to cardiopulmonary causes (at baseline and during disease progression).
• Depression test
• Health check (for follow-up treatment)

Further notes

• Investigation of blood pressure behavior during a Valsalva maneuver (forced exhalation against the closed mouth and nasal opening with simultaneous use of the abdominal press; Alternatively: blow so hard into a 10 ml syringe that the plunger begins to move. Duration: 15 sec!). During the forced expiration described in this way, a drop in blood pressure occurs in a healthy person.This is due to the fact that less blood flows from the pulmonary circulation into the left ventricle during tension. In the presence of increased left ventricular filling pressure, on the other hand, blood pressure initially rises, remains elevated during tension and only falls again when the tension is released.

Square brackets [ ] indicate possible pathological (pathological) physical findings.

Score for early diagnosis of heart failure

Legend: ≥ 21 points = indication for echocardiography; negative predictive value of 87% and positive predictive value of 73%.