Evidence-Based Physical Exam: Heart Failure

The Approach

In general, the approach to the physical exam in patients with heart failure (HF) has multiple features:

  • General: VS, appearance
  • Neck: Jugular venous pressure (JVP), hepatojugular reflux (HJR; aka abdominojugular reflux)
  • Cardiac: Auscultation for murmurs/S3/S4; palpation of PMI
  • Pulmonary: Auscultation for crackles, diminished breath sounds, and wheezing; assess bendopnea
  • Abdomen: Palpation for hepatomegaly and ascites
  • Extremities: Palpation for edema, pulses, and coolness of extremities
Source: Chen et al. Med Clin North Am. 2022

Jugular Venous Pressure

JVP is a proxy for measuring central venous pressure. The best definition of elevated JVP appears to be when the top of the internal jugular vein is ≥3cm above the sternal angle.

Evaluating JVP is challenging, but it’s helpful to keep a few points in mind:

CHARACTERISTICVENOUS PULSECAROTID PULSE
WaveformDiffuse biphasicSingle sharp
Positional changeVaries with positionNo variation
Respiratory variationHeight falls on inspirationNo variation
Effect of palpationWave non-palpable
Pressure obliterates pulse
Pulse palpable
Not compressible
Abdominal pressureDisplaces pulse upwardsPulse unchanged
Source: The Rational Clinical Examination, JAMA. 2009

General approach:

  1. Stand on patient’s right and elevate bed or exam table to ~45º
  2. Patient’s neck should be slightly extended and head turned slightly to the left
  3. Identify the venous meniscus (highest point of pulsation in the right internal jugular vein)
  4. JVP the vertical distance (in cm) between the venous meniscus and the sternal angle (the junction of the manubrium with the body of the sternum)
    • CVP is the JVP plus 5 cm (roughly the distance of the sternal angle above the right atrium)
    • JVP is best measured at the end of expiration
    • Pro tip: Measure the width of your fingers. The width of 2 digits is probably close to 3 cm. Knowing this (or having it on hand?!) is much more efficient than fumbling around for a ruler, which will never be around when you need it
Source: The Rational Clinical Examination, JAMA. 2009
  • Note that the most common error in measuring JVP is underestimation. Measurement is also unreliable in patients with low CVP, those on mechanical ventilation, or those with short/thick necks
  • The external jugular vein, although sometimes easier to see than the internal jugular vein, may be constricted as it passes through the fascial planes of the neck and thus may not accurately reflect right atrial pressures
  • Despite the traditionally held idea that the sternal angle is 5 cm above the right atrium, the distance appears to change substantially depending on the patient’s position

Interested in learning more? Check out this fantastic post on PDX! 

Hepatojugular Reflux

General approach:

  1. Position the patient for JVP assessment and identify the JVP
  2. Apply moderate pressure to the mid-abdomen and hold for ~30 seconds
  3. Positive finding is a sustained increase in JVP ≥4cm followed by a drop in JVP with release of pressure
  • False positives may occur if the patient strains (i.e., Valsalva) or experiences pain during the maneuver.
  • Healthy individuals may exhibit one of 3 responses to abdominal compression: no change in JVP; a transient (few seconds) increase of more than 4 cm that returns to its former level or near the baseline before 10 seconds, with little or no decrease when abdominal pressure is released; or an increase of more than 3 cm sustained throughout compression.

Valsalva Response

A lesser known part of the exam is the Valsalva response, which refers to the changes in BP that occur during both the strain phase of the Valsalva maneuver and the recovery period after the strain is released.

General approach:

  1. Measure the patient’s BP, then inflate the cuff to 15 mmHg above the SBP
  2. Ask the patient to bear down (i.e. perform the Valsalva maneuver)
  3. Analyze the Korotkoff sounds throughout the 4 phases of the Valsalva maneuver:
    • Phase I (onset of strain causes transient increase in SBP due to the emptying of blood from the pulmonary veins): Korotkoff sounds are heard in both the healthy patient and patient with HF
    • Phase II (maintenance of strain causes increase in intrathoracic pressure that leads to a decrease in venous return and cardiac preload): BP decreases in the healthy patient and Korotkoff sounds are no longer heard; however, in patients with HF, there may not be a decrease in BP during this phase because the LV remains filled due to elevated LV pressures before straining (i.e., Korotkoff sounds may be present or absent in phase II for patients with HF)
    • Phase III (release of strain) and phase IV (after release of strain): Healthy patients respond with an overshoot of BP above baseline (phase IV) due to the return of normal venous blood flow to the heart and Korotkoff sounds are heard again. In the patient with HF, Korotkoff sounds are not heard in phase IV due to the inability of the heart to respond with an increase in the cardiac output.
Source: Chen et al. Med Clin North Am. 2022
  • Beta blockers may result in a false-positive result by preventing the phase IV overshoot of BP.

Take-Home Points!

  • No exam finding is 100% sensitive or specific
  • JVP isn’t a great surrogate marker of CVP, but still useful in determining venous congestion
  • The Valsalva response is underutilized but has a relatively significant likelihood ratio
  • Palpating the PMI is helpful (and not just for OSCEs!)

Blog post based on Med-Peds Forum by Laura Schwartz, PGY2, and Fritz Siegert, PGY4

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