Exam

The Heart Failure Physical Exam

The focus of the examination of a heart failure patient is to determine the severity of the condition. In addition, like the history, the exam also functions to direct the search for an etiology. 

Heart failure can result from virtually any severe form of heart disease and findings on examination can often pinpoint the causative pathology and direct further diagnostic efforts leading  to more effective treatment.  

A systematic approach from head to toe will yield the most information. Below are some conditions associated with various cardiac examination findings:  

Non-cardiac exam clues

  •  Exophthalmos occurs in patients with hyperthyroidism
  •  Roth spots in retinal exam occurs in infective endocarditis
  • Papilledema is seen in patients with malignant hypertension
  • Central cyanosis  is seen with right-to-left shunting congenital heart disease
  • Clubbing of the finger tips is also characteristic of hypoxic pulmonary diseases
  • Bronze coloration of skin with loss of axillary and pubic hair is classic finding of advanced hemochromatosis
  • Jaundiced skin suggests right sided failure with liver congestion 
  • Abdominal pain on palpation suggests enlarged liver RUQ) or spleen LUQ) due to CHF 
  • Unilateral edema in one leg suggests DVT  or lymphatic disease 
  • Rales (crackles) on lung exam are very specific for congestive heart failure

Problems with Pulse

  •  Low amplitude pulse suggests low cardiac output
  • Wide pulse pressure is classic for severe aortic regurgitation or a patent ductus arteriosus but in patient with heart failure also think about sepsis and severe anemia 
  • Bisferiens pulse is a double tap on the fingers and is seen in patients with severe aortic regurgitation or with moderate to severe combined aortic regurgitation and aortic stenosis 
  • Pulsus alternates is shifting strength of the pulse on your fingers from strong to weak and is typical of patients with severe  depression of left ventricular function
  • Pulsus paradoxus is exaggeration of the decline in arterial pressure with inspiration. It results from the reduced left ventricular stroke volume and the transmission of negative intrathoracic pressure to the aorta. It is a frequent, indeed characteristic, finding in patients with cardiac tamponade, 41,42 occurs less frequently (in about half) in patients with chronic constrictive pericarditis,

Clues from Heart Sounds

  • First heart sound (S1) is made by closure of the mitral valve (first component) and the tricuspid valve (second component) signifying the onset of systole
  • Second heart sound ( S 2) is made by closer of the aortic valve (A2) and pulmonic valve (P2) signifying the onset of diastole
  •  A loud S1 suggests poor LV compliance, mitral stenosis, or  left atrial mass (myxoma)
  • Soft S1 can be seen with reduced left ventricular contractility, acute aortic regurgitation or  left bundle branch block
  • A patient with severe edema, ascites, hepatic congestion, and an  opening “snap” os S1 likely has rheumatic mitral valve stenosis
  • S2 is normally split into A2 and P2 components and a single (unspilt) S2 is seen in severe calcific aortic stenosis of the elderly
  • Wide splitting of S2 can be seen with delayed pulmonic closure caused by RBBB,  pulmonary stenosis or pulmonary hypertension   
  • Fixed wide splitting of S2 is consistent with  ostium secundum atrial septal defect
  • Paradoxically split S2 is seen when aortic valve closure is delayed such as with severe aortic stenosis, hypertrophic obstructive cardiomyopathy
  •  S3 (mid-diastolic sound) is caused by severe LV dysfunction and systolic heart failure 
  • S4 (late diastoli/presystolic sound) is due to filling of stiff ventricle and is present in LVH, hypertensive heart disease, and heart failure from severe diastolic dysfunction. 

Systolic Murmurs

Mid systolic murmurs

  • Aortic stenosis
  • Pulmonic stenosis
  • Atrial septal defect
  • Hypertrophic cardiomyopathy 

Holosystolic murmurs

  • Mitral regurgitation
  • Tricuspid regurgitation
  • Ventricular septal defect

Late systolic murmur

  • Mitral valve prolapse

Diastolic Murmurs

Early Diastolic Murmur

  • Aortic regurgitation 
  • Pulmonic regurgitation

Mid diastolic murmur

  • Mitral stenosis
  • Tricuspid stenosis

Continuous murmurs

  • Patent ductus arteriosus

Causes of Friction "Rub"

  • Infectious (viral, bacterial or fungal)
  • Acute myocardial infarction (Dressler’s)
  • Post-cardiotomy syndrome
  • Malignancy (primary or metastatic)
  • Uremia
  • Myxedema
  • Radiation therapy
  • Systemic lupus
  • Wegener’s disease
  • Sarcoidosis
  • Doxorubicin
  • Hydralazine
  • Dantrolene
  • Procainamide
  • Phenytoin