JACC: HEART FAILURE VOL. -, NO.

-, 2018
ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

STATE-OF-THE-ART PAPER

The Role of the Clinical Examination in

Patients With Heart Failure
Jennifer T. Thibodeau, MD, MSCS, Mark H. Drazner, MD, MSC

ABSTRACT

Despite advances in biomarkers and technology, the clinical examination (i.e., a history and physical examination) remains
central in the management of patients with heart failure. Specifically, the clinical examination allows noninvasive
assessment of the patient’s underlying hemodynamic state, based on whether the patient has elevated ventricular filling
pressures and/or an inadequate cardiac index. Such assessments provide important prognostic information and help guide
therapeutic decision-making. Herein, we critically assess the utility of the clinical examination for these purposes and
provide practical tips we have gleaned from our practice in the field of advanced heart failure. We note that the ability to
assess for congestion is superior to that for inadequate perfusion. Furthermore, in current practice, elevated left
ventricular filling pressures are inferred by findings related to an elevated right atrial pressure. We discuss an
emerging classification system from the clinical examination that categorizes patients based on whether elevation
of ventricular filling pressures occurs on the right side, left side, or both sides. (J Am Coll Cardiol HF 2018;-:-–-)
© 2018 by the American College of Cardiology Foundation.

D espite technological advances, the clinical

examination (i.e., a history and physical ex-
amination [H&P]) remains fundamental in
the management of patients with heart failure (HF).
Stevenson (Figure 1A) (1). A patient is said to be wet if
the estimated pulmonary capillary wedge pressure
(PCWP) is $22 mm Hg; otherwise, the patient is
considered dry. Likewise, if the estimated cardiac
As with any diagnostic test, the strengths and limita- index (CI) is #2.2 l/min/m 2, a patient is said to be
tions of the clinical examination should be assessed cold; otherwise, the patient is classified as warm.
critically. The purpose of this review is to summarize Thus, it becomes important to understand how each
the current role of the clinical examination in deter- of these axes (volume status and perfusion) can be
mining the hemodynamic state and prognosis of assessed by the clinical examination.
patients with HF. Rather than providing a review of
the comprehensive clinical examination, we focus VOLUME STATUS
on those components we believe are most useful in
the routine care of such patients. We also highlight The determination of wet is based on the presence of
an emerging classification based on the pattern of any sign or symptom that is associated with elevated
ventricular filling pressure elevation. ventricular filling pressures. Such findings on the
The clinical examination can be used to assess the clinical examination include jugular venous disten-
underlying hemodynamic state of patients with HF. tion (JVD), hepatojugular reflux (HJR), orthopnea,
Patients can be categorized based on clinician- bendopnea, and a square-wave response in blood
estimated volume status (wet/dry) and perfusion pressure (BP) during the Valsalva maneuver. The
status (warm/cold), as suggested by Dr. Lynne detection of volume depletion, the opposite side of

From the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas,
Texas. Dr. Drazner acknowledges research support from the James M. Wooten Chair in Cardiology. Dr. Thibodeau has reported
that she has no relationships relevant to the contents of this paper to disclose.

Manuscript received October 27, 2017; revised manuscript received March 26, 2018, accepted April 3, 2018.

ISSN 2213-1779/$36.00 https://doi.org/10.1016/j.jchf.2018.04.005

2 Thibodeau and Drazner JACC: HEART FAILURE VOL. -, NO. -, 2018
Clinical Examination in Heart Failure - 2018:-–-

ABBREVIATIONS the spectrum of volume status, can be mortality (4), findings consistent with those seen in
AND ACRONYMS assessed by orthostatic changes in BP and SOLVD (12). An inspiratory increase in the venous
heart rate, which has been reviewed else- pressure, equivalent to Kussmaul’s sign, was also an
BP = blood pressure
where (2). adverse prognostic marker in patients with advanced
CI = cardiac index
JUGULAR VENOUS DISTENTION. JVD, or an HF (15). Thus, the JVP is useful not only in the
H&P = history and physical
elevated jugular venous pressure (JVP), has assessment of fluid status but also in identifying pa-
examination
been found to be the most useful H&P finding tients with higher risk of adverse outcomes.
HF = heart failure
for assessing ventricular filling pressures (3). HEPATOJUGULAR REFLUX. The HJR is an increase in
HJR = hepatojugular reflux
JVD is described as an estimated JVP $10 cm JVP by >3 cm sustained during 10 seconds of
JVD = jugular venous
distention H2O (4). Estimates of cm H2 O can be con- continuous pressure on the abdomen, with an abrupt
JVP = jugular venous pressure
verted to mm Hg using the relationship 1.36 fall after the pressure is released (16). Testing for HJR
cm H 2O ¼ 1 mm Hg (5). If the internal jugular may improve detection of elevated ventricular filling
PCWP = pulmonary capillary
wedge pressure vein is difficult to appreciate, then assess- pressures because the presence of HJR, in the absence
RAP = right atrial pressure ment via the external jugular vein is accept- of isolated right ventricular systolic dysfunction,
able (6). Some practical tips for the reliably predicts PCWP >15 mm Hg (17). In a study of
examination of the JVP are listed in Table 1. 52 patients referred for cardiac transplantation eval-
JVD is common in patients admitted with decom- uation, 42% of patients had HJR, and all but 1 of these
pensated HF (7,8). Assessment of the JVP can be patients had PCWP $18 mm Hg. Additionally, there
used to estimate right atrial pressure (RAP) and was good interobserver agreement in the assessment
guide therapy (6,7,9). Cardiology faculty were more of HJR (8). In total, these findings suggest that HJR
accurate than fellows in estimating the JVP (10), thus can be useful in identifying patients with elevated
emphasizing the importance of developing clinical PCWP.
examination skills. In ESCAPE (Evaluation Study Similar to JVD, the presence of HJR indicates worse
of Congestive Heart Failure and Pulmonary Artery prognosis in patients with HF. In a post hoc analysis
Catheterization Effectiveness), a pre-specified sec- of ESCAPE, patients with persistent versus resolved
ondary objective was to assess the utility of skilled HJR on discharge had a higher risk of 6-month mor-
clinician assessment, via the H&P, of the hemody- tality (univariate odds ratio: 2.2; 95% confidence in-
namic status of patients with advanced HF (Table 2) terval: 1.2 to 3.9; p ¼ 0.012). Furthermore, those with
(11). The JVP was categorized into 3 groups (<8, 8 to 12, HJR and JVD on discharge had higher 6-month mor-
>12 mm Hg), and these H&P-guided estimates were tality compared with those with HJR alone (33.8% vs.
associated with the invasively measured RAP (area 16.7%, respectively; p ¼ 0.045) (18). Thus, evaluation
under the curve: 0.74) (7). Finally, in ESCAPE, JVD was for both JVD and HJR not only at admission but also at
1 of only 2 parameters from the clinical examination discharge provides prognostic information in patients
(the other being orthopnea $2 pillows) that was with HF.
associated with an elevated PCWP (7).
ORTHOPNEA. Orthopnea, or dyspnea when supine,
The prognostic implications of JVD have been
was associated with elevated PCWP in ESCAPE,
examined. In SOLVD (Study of Left Ventricular
whether defined as $28 mm Hg, $30 mm Hg, or $32
Dysfunction), symptomatic patients with HF with
mm Hg (7). Both orthopnea and JVD remained asso-
JVD, an S 3 gallop (third heart sound), or both, were at
ciated with PCWP $30 mm Hg independent of each
significantly increased risk of hospitalization for HF,
other in multivariable models, suggesting they pro-
composite of death or hospitalization for HF, and
vide additive information. As such, during the clinical
death from pump failure (12). In patients with
examination, we routinely assess our patients for
asymptomatic left ventricular dysfunction, both an S3
orthopnea to estimate whether their left ventricular
gallop and JVD were associated with an increased risk
filling pressures are elevated.
of development of HF and the composite endpoint of
A recent composite “orthodema” score based on
death or development of HF in multivariable models
the presence and severity of orthopnea and edema
(13). Subsequently, a propensity-matched population
has been proposed (19). An increased orthodema
of patients with and without JVD did not demonstrate
score was associated with morbidity and mortality in
an association of JVD with outcomes (14). However, in
patients with HF (19).
a more recent study of more than 2,000 patients
admitted with acute HF, JVD was associated with an RESPONSE TO VALSALVA MANEUVER. The BP
increased risk of in-hospital adverse events and response to the Valsalva maneuver also allows esti-
increased 30-day, 1-year, and 10-year all-cause mation of the PCWP. In healthy individuals, the BP
JACC: HEART FAILURE VOL. -, NO. -, 2018 Thibodeau and Drazner 3
- 2018:-–- Clinical Examination in Heart Failure

F I G U R E 1 Assessing Hemodynamic Profiles in Patients With Heart Failure

(A) Hemodynamic profiles are based on volume status and adequacy of perfusion. (B) Potential therapeutic implications of classification of
hemodynamic profiles. CI ¼ cardiac index; PCWP ¼ pulmonary capillary wedge pressure.

drops during the strain phase due to a decrease a means of noninvasively determining left ventricular
in pulmonary venous return to the left ventricle. filling pressures (22,23,27).
In contrast, in patients with elevated left-sided filling
pressure, a square-wave pattern of response is seen. BENDOPNEA. Bendopnea, as we recently defined in
The BP rises with strain and remains stably elevated an advanced HF population (28), is a symptom of
throughout the strain, returning to baseline only dyspnea that is elucidated by bending forward at the
when the strain is released. Note that there is no waist (Figure 2). Bendopnea was assessed by having
decrease in BP during the strain despite decreased the patient bend forward while sitting in a chair and
pulmonary venous return, as occurs in healthy in- touching one’s feet with one’s hands. Concurrently,
dividuals, because the left ventricle remains an examiner told the patient not to hold his or her
adequately filled given the pre-strain elevated left breath, then at 10-second intervals asked the patient
ventricular filling pressure (20,21). The square-wave if he or she was experiencing difficulty breathing.
response to the Valsalva maneuver was associated Bendopnea was considered present if dyspnea
with the invasively measured PCWP (22–26). The occurred within 30 s of bending (28). In the initial
square-wave response will not be present if there is study of 102 patients with systolic HF undergoing
isolated elevation in right ventricular filling pressure. right heart catheterization, bendopnea was present in
Devices that allow quantitative assessment of BP in a sizeable minority of patients (approximately one-
response to the Valsalva maneuver are being tested as third) and was associated with increased filling
4 Thibodeau and Drazner JACC: HEART FAILURE VOL. -, NO. -, 2018
Clinical Examination in Heart Failure - 2018:-–-

T A B L E 1 Practical Tips When Assessing the JVP F I G U R E 2 Assessment of Bendopnea

1. Start by assessing the patient sitting upright to exclude a very high

JVP, which may be more difficult to detect when at a lower angle.
2. Look for a waveform/pulsation rather than an actual venous
structure. Shining a light tangentially across the neck may help you
see the waveform.
3. If the patient is in bed, excess pillows may flex the neck, making the
jugular veins hard to see; thus, we recommend leaving only 1 pillow.
Slightly tipping the chin upward often improves the visibility of the
jugular waveform.
4. Inspect both sides of the neck because the waveform may be seen
better on either the right or the left. In a small minority of patients,
the jugular venous waveform is seen best in the front of the neck
(i.e., midline above the 2 clavicular heads).
5. If the internal jugular venous waveform is not visible, the external
jugular vein can be used to estimate the JVP. Confirm a
respirophasic component in the external jugular vein before
accepting it as a measure of the JVP.
6. Assess the JVP with the patient at various angles off the horizontal
(e.g., supine, at 30 –45 , sitting, or standing) until the pulsation is
visible approximately halfway up the neck. Note that a high JVP can
be hard to see in the supine position so a good practice is to also
A patient sits in a chair, bends at the waist, and touches his or
look at the neck veins with the patient sitting up.
her feet. Bendopnea is considered present if dyspnea occurs
7. To distinguish the carotid from the jugular venous impulse, apply
pressure with your finger 1–2 inches below the impulse. If the within 30 s of bending.
pulsation disappears, it was the jugular vein; if the pulsation
persists, it was the carotid artery.
8. A respirophasic pattern (typically a decrease with inspiration, but in
some patients the JVP increases with inspiration, known as the
Kussmaul sign) and positional changes (i.e., pulsation moves lower
Bendopnea may have prognostic utility in HF. Pa-
in the neck when the patient is more upright) also help establish the tients with bendopnea had a higher minute ventila-
waveform as venous rather than arterial.
tion to carbon dioxide production (VE/V CO2) slope
9. If the JVP does not seem elevated when the patient is supine, press
on the abdomen to determine whether an HJR is present. Note that (29), which is a validated prognostic marker in HF
in many patients, the JVP will transiently rise (i.e., flicker upward for (33). In a study of 250 patients admitted with
1–2 s) when abdominal pressure is first applied but then return to
normal. Although such a finding is not considered a positive HJR, decompensated HF, bendopnea was associated with
which requires sustained elevation over 10 s, it will help the increased 6-month mortality in univariable but not
examiner be certain that the maximal height of the jugular venous
column was seen (and the JVP was not underestimated). multivariable analysis (30). In a study of ambulatory
patients with HF, bendopnea was associated with an
HJR ¼ hepatojugular reflux; JVP ¼ jugular venous pressure.
increased risk of a composite endpoint at one year of
death, HF admission, inotrope initiation, left ven-
tricular assist device implantation, or cardiac trans-
pressures, particularly in the setting of low CI (28).
plantation in univariable but not multivariable
Four additional studies have confirmed that bend-
analysis (32). In that study, bendopnea was more
opnea is common (18% to 49%) in patients with HF,
strongly associated with short-term outcomes such as
including those in a primary care clinic or HF clinic,
HF admission at 3 months.
those referred for cardiopulmonary exercise testing,
Although bendopnea was associated with elevated
and patients admitted with decompensated HF (29–
filling pressures in patients with HF, it is not diag-
32).
nostic of HF and may also occur in other disease
processes. For example, bendopnea was reported
T A B L E 2 Utility of Clinical Findings in Detecting PCWP with allergic bronchopulmonary aspergillosis (34) and
>22 mm Hg in Patients With Advanced Heart Failure in ESCAPE
likely can be present in patients with other pulmo-
Clinical Finding Sensitivity Specificity PPV NPV nary diseases or in the morbidly obese. These exam-
Rales $1/3 15 89 69 38 ples do not minimize the potential importance of
Edema $2þ 41 66 67 40 bendopnea in assessing patients with HF, just as the
Orthopnea $2 pillows 86 25 66 51
presence of orthopnea and edema in obese subjects
JVP $12 mm Hg 65 64 75 52
does not diminish the importance of these classic
HJR 83 27 65 49
signs of HF.
Adapted with permission from Drazner et al. (7).
PERFUSION
ESCAPE ¼ Evaluation Study of Congestive Heart Failure and Pulmonary Artery
Catheterization Effectiveness; NPV ¼ negative predictive value; PCWP ¼ pulmo-
nary capillary wedge pressure; PPV ¼ positive predictive value; other abbreviations
as in Table 1.
In addition to assessing volume status, the clinical
examination can be used to assess the adequacy of
JACC: HEART FAILURE VOL. -, NO. -, 2018 Thibodeau and Drazner 5
- 2018:-–- Clinical Examination in Heart Failure

perfusion (Figure 1A). Although there are multiple these findings have limitations. In advanced chronic
useful clinical examination findings to determine an HF, patients with elevated left ventricular filling
elevated PCWP (see ”Volume status” section), there pressures may not have rales (8,35–37) because of an
are fewer reliable findings to determine a low CI. Such increase in lymphatic drainage. Indeed, in our expe-
findings include narrow pulse pressure, cool ex- rience of caring for patients with advanced HF,
tremities, a global assessment of cold made by the outside of the setting of ischemia and “flash” pul-
clinician, and possibly bendopnea. monary edema, rales are more often a reflection of a
A low pulse pressure (systolic pressure – diastolic pulmonary process (e.g., pneumonia) than of pul-
pressure) or a low proportional pulse pressure monary edema. Likewise, patients with HF may have
[(systolic pressure – diastolic pressure)/systolic clear lung fields on radiographic imaging despite
pressure] can be a marker of a low CI. In a study of having elevated filling pressures (36,38).
50 patients with chronic HF undergoing hemody- Peripheral or dependent edema may be common,
namic assessment with right heart catheterization, but it represents extravascular rather than intravas-
the proportional pulse pressure correlated well with cular volume. Edema can be the result of another
CI (r ¼ 0.82; p < 0.001) (35). However, in ESCAPE, condition, such as venous insufficiency, obesity,
proportional pulse pressure <25% had good positive lymphedema, nephrotic syndrome, or cirrhosis.
predictive values for low CI, but it was relatively Rapid accumulation of bilateral leg edema with
infrequent and was not significantly associated with associated weight gain in patients with a known his-
CI #2.2 l/min/m 2 (7). tory of HF usually does represent volume expansion,
There is even less supporting evidence for the although it occurs late in the process of decompen-
other putative clinical findings of low CI. In ESCAPE, sation. Its specificity as a sign is increased in the
the clinician’s overall assessment of a cold profile was presence of elevated JVP, but it should not be used
significantly associated with CI #2.2 l/min/m 2 alone to suggest elevated filling pressures (35).
(odds ratio: 2.97; 95% confidence interval: 1.2 to 7.1;
UTILITY OF THE
p ¼ 0.015) (7). As described in the “bendopnea”
STEVENSON CLASSIFICATION
section, bendopnea was associated not only with
elevated filling pressures but also with low CI (28).
The Stevenson profiles provide prognostic informa-
Cool extremities are consistent with poor perfusion,
tion (1,7). In a single-center observational study, the
although it is important to recognize that an exam-
admission H&P-assessed hemodynamic profile of B
iner’s perception of the temperature of the patient’s
(warm and wet) or C (cold and wet) was an indepen-
legs is dependent on whether the examiner’s own
dent risk factor for the composite endpoint of mor-
hands are warm or cold. Furthermore, we have noted
tality or urgent transplant at 1 year (1). In ESCAPE,
repeatedly that patients whose legs feel warm to the
physician assessment of discharge hemodynamic
touch can have a low CI, suggesting that this finding
profiles of wet or cold, versus profile A (warm and dry),
has low sensitivity. Indeed, in ESCAPE, sensitivity
was associated with a 50% increased risk of rehospi-
was only 20% for this finding (7).
talization or death, independent of other markers of
Overall, our clinical experience suggests that
disease severity (7). The value of serial assessment
although ventricular filling pressures can be assessed
throughout hospitalization was evident, as the
with some confidence, estimation of the CI is more
patients who were admitted wet or cold but were dis-
challenging. It is particularly important to recognize
charged in profile A did not have increased event rates
this limitation when assessing patients who are not
after discharge, while the patients at high risk were
responding favorably to therapy guided by the clin-
those who were discharged while still cold or wet.
ical examination. Specifically, a low CI should be
The Stevenson profile can also be used to guide
considered in the differential diagnosis for worsening
therapy. Occasionally, a patient is admitted to the
renal function during diuresis in a patient with
hospital with a presumed diagnosis of decompensated
decompensated HF, even if the clinical examination
HF, yet the clinical examination suggests that the pa-
suggests the patient is well perfused.
tient is compensated (profile A, warm and dry). In such
PHYSICAL EXAMINATION FINDINGS LESS cases, alternative causes of the patient’s symptoms
USEFUL IN ASSESSING HEMODYNAMICS IN HF need to be considered (e.g., in the appropriate setting,
amiodarone lung toxicity or pneumonia). The Ste-
Although pulmonary rales, pleural effusions, and venson profile can also be used to guide decision-
peripheral edema can be seen in decompensated HF, making as to whether vasodilators or inotropes
6 Thibodeau and Drazner JACC: HEART FAILURE VOL. -, NO. -, 2018
Clinical Examination in Heart Failure - 2018:-–-

F I G U R E 3 Classification of Congestion Based on Clinical Assessment of Elevated Right- or Left-Sided Filling Pressure

HJR ¼ hepatojugular reflux; JVD ¼ jugular venous distention; PCWP ¼ pulmonary capillary wedge pressure; RAP ¼ right atrial pressure.

should be added to intravenous diuretics in patients REFINING THE ASSESSMENT OF

admitted with decompensated HF. In our practice, if a CONGESTION BASED ON WHETHER
patient is profile B, we administer diuretics, reasoning VENTRICULAR FILLING PRESSURES
that there is no role for inotropic therapy when ARE ELEVATED ON THE RIGHT SIDE,
perfusion is adequate. In contrast, if the patient is LEFT SIDE, OR BOTH
profile C, we add either a vasodilator or inotrope to the
diuretics (Figure 1B). Given the challenges in esti- Currently, most clinical markers of volume overload
mating CI (see “Perfusion” section), we recognize that (e.g., JVD, peripheral edema, or ascites) reflect
some patients thought to be profile B are actually elevated right-sided filling pressures. Although it is
profile C, but we believe this framework is reasonable true that an elevation in RAP mirrors an elevation in
when choosing the initial therapeutic approach in PCWP in most patients with HF, approximately 25%
hospitalized patients with decompensated HF. to 30% of patients have discordance between right-
and left-sided filling pressures, with an isolated
INTEGRATING NATRIURETIC PEPTIDES WITH elevation on either side (41–44). Discordance can
THE CLINICAL EXAMINATION occur in those with preserved or reduced ejection
fraction (41–44). The pattern of elevated filling pres-
Even in the absence of clinical findings of congestion, sures (right-sided only, left-sided only, or both) has
patients with HF can have elevated left ventricular some degree of consistency when reassessed over
filling pressures, a condition called “hemodynamic time (41,43).
congestion” (2). One method for identifying hemo- To refine the clinical assessment of the congested
dynamic congestion is to measure natriuretic pep- state, patients can be classified based on whether the
tides, neurohormones released in response to stretch right- or left-sided ventricular filling pressures, or
of the left ventricular walls. Measurement of natri- both, are elevated (Figure 3). Although this classifi-
uretic peptides, in addition to the clinical examina- cation system may more accurately characterize the
tion, can improve the diagnosis and risk stratification type of volume overload, whether patients with iso-
of patients with HF (39). Although the hypothesis lated right- or left-sided filling pressure elevation
that adjusting therapy by serial measurement of have a different response to treatment or prognosis
natriuretic peptide levels rather than by clinical than those with concordant pressures is not yet
assessment could improve outcomes in patients with known. A disproportionate elevation of the right- to
HF was attractive, this was not the case in the left-sided ventricular pressures, as assessed by an
recently completed Guiding Evidence-Based Therapy elevated RAP/PCWP ratio (termed a “right-left
Using Biomarker Intensified Treatment (GUIDE-IT) equalizer” pattern when $0.67), has been shown to
trial (40). be associated with impaired renal function (45) and
JACC: HEART FAILURE VOL. -, NO. -, 2018 Thibodeau and Drazner 7
- 2018:-–- Clinical Examination in Heart Failure

C ENTR AL I LL U STRA T I O N Clinical Assessment of Hemodynamics in Patients with Heart Failure

Thibodeau, J.T. et al. J Am Coll Cardiol HF. 2018;-(-):-–-.

This classification incorporates information on whether right- and/or left-sided ventricular filling pressures are estimated to be elevated. Note that both a dispro-
portionately elevated ratio of RAP to PCWP (in the setting of persistently elevated JVD) and a low CI (despite a clinical assessment that the patient is warm) are in the
differential diagnosis for worsening renal function during diuresis. CI ¼ cardiac index; HJR ¼ hepatojugular reflux; JVD ¼ jugular venous distention; PCWP ¼ pulmonary
capillary wedge pressure; RAP ¼ right atrial pressure.

worse outcome (43,46), providing preliminary sup- patients with HF. With regard to the patient’s he-
port for this classification system. A disproportion- modynamic state, the clinical examination is more
ately elevated ratio of RAP to PCWP should be in the accurate in the assessment of elevated ventricular
differential diagnosis when a patient with persis- filling pressures than in the detection of a low CI.
tently elevated JVP develops worsening renal func- Currently, elevated left ventricular filling pressures
tion during diuresis. Further investigation of the are inferred largely from clinical findings related to
characteristics and outcomes of these hemodynamic an elevated RAP. An emerging classification system
profiles is warranted. An overall approach to the characterizes patients based on whether congestion
clinical examination incorporating this approach is occurs on the right side, left side, or both. Given
shown in the Central Illustration. these considerations, in patients with decom-
pensated HF and worsening renal function during
CONCLUSIONS diuresis, a low CI (even if perceived to be well
perfused) and a right-left equalizer pattern of
The clinical examination provides information ventricular filling pressures (when JVP is persis-
regarding the hemodynamic state and prognosis of tently elevated) should be included in the
8 Thibodeau and Drazner JACC: HEART FAILURE VOL. -, NO. -, 2018
Clinical Examination in Heart Failure - 2018:-–-

differential diagnosis. Further studies are needed to

determine whether a classification based on right- ADDRESS FOR CORRESPONDENCE: Dr. Mark Drazner,

versus left-sided congestion can be used to Division of Cardiology, Department of Internal Medi-
improve risk stratification and guide treatment de- cine, University of Texas Southwestern Medical Center,
cisions for patients with HF, and thereby improve 5323 Harry Hines Boulevard, Dallas, Texas 75390-9047.
outcomes. E-mail: mark.drazner@utsouthwestern.edu.

REFERENCES

1. Nohria A, Tsang SW, Fang JC, et al. Clinical failure in patients with asymptomatic left ven- reflect myocardial dysfunction? Chest 1989;95:
assessment identifies hemodynamic profiles that tricular dysfunction. Am J Med 2003;114:431–7. 986–91.
predict outcomes in patients admitted with heart
14. Meyer P, Ekundayo OJ, Adamopoulos C, et al. 27. Gilotra NA, Tedford RJ, Wittstein IS, et al.
failure. J Am Coll Cardiol 2003;41:1797–804.
A propensity-matched study of elevated jugular Usefulness of pulse amplitude changes during the
2. Gheorghiade M, Follath F, Ponikowski P, et al. venous pressure and outcomes in chronic heart Valsalva maneuver measured using finger photo-
Assessing and grading congestion in acute heart failure. Am J Cardiol 2009;103:839–44. plethysmography to identify elevated pulmonary
failure: a scientific statement from the acute heart capillary wedge pressure in patients with heart
15. Nadir AM, Beadle R, Lim HS. Kussmaul physi-
failure committee of the heart failure association failure. Am J Cardiol 2017;120:966–72.
ology in patients with heart failure. Circ Heart Fail
of the European Society of Cardiology and 28. Thibodeau JT, Turer AT, Gualano SK, et al.
2014;7:440–7.
endorsed by the European Society of Intensive Characterization of a novel symptom of advanced
Care Medicine. Eur J Heart Fail 2010;12:423–33. 16. Ducas J, Magder S, McGregor M. Validity of the heart failure: bendopnea. J Am Coll Cardiol HF
hepatojugular reflux as a clinical test for conges- 2014;2:24–31.
3. Cohn JN. Jugular venous pressure monitoring: a
tive heart failure. Am J Cardiol 1983;52:1299–303.
lost art? J Card Fail 1997;3:71–3. 29. Dominguez-Rodriguez A, Thibodeau JT,
17. Ewy GA. The abdominojugular test: technique Abreu-Gonzalez P, et al. Association between
4. Chernomordik F, Berkovitch A, Schwammenthal E,
and hemodynamic correlates. Ann Intern Med bendopnea and key parameters of cardiopulmo-
et al. Short- and long-term prognostic implications of
1988;109:456–60. nary exercise testing in patients with advanced
jugular venous distension in patients hospitalized
with acute heart failure. Am J Cardiol 2016;118: 18. Omar HR, Guglin M. Clinical and prognostic heart failure. J Card Fail 2016;22:163–5.
226–31. significance of positive hepatojugular reflux on 30. Baeza-Trinidad R, Mosquera-Lozano JD, El
discharge in acute heart failure: insights from the Bikri L. Assessment of bendopnea impact on
5. McGee SR. Physical examination of venous
ESCAPE trial. Biomed Res Int 2017;2017:5734749. decompensated heart failure. Eur J Heart Fail
pressure: a critical review. Am Heart J 1998;136:
2017;19:111–5.
10–8. 19. Lala A, McNulty SE, Mentz RJ, et al. Relief and
recurrence of congestion during and after hospi- 31. Martinez Ceron DM, Garcia Rosa ML, Lagoeiro
6. Vinayak AG, Levitt J, Gehlbach B, Pohlman AS,
talization for acute heart failure: insights from Jorge AJ, et al. Association of types of dyspnea
Hall JB, Kress JP. Usefulness of the external ju-
Diuretic Optimization Strategy Evaluation in Acute including ’bendopnea’ with cardiopulmonary dis-
gular vein examination in detecting abnormal
Decompensated Heart Failure (DOSE-AHF) and ease in primary care. Rev Port Cardiol 2017;36:
central venous pressure in critically ill patients.
Cardiorenal Rescue Study in Acute Decom- 179–86.
Arch Intern Med 2006;166:2132–7.
pensated Heart Failure (CARESS-HF). Circ Heart
32. Thibodeau JT, Jenny BE, Maduka JO, et al.
7. Drazner MH, Hellkamp AS, Leier CV, et al. Value Fail 2015;8:741–8.
Bendopnea and risk of adverse clinical outcomes in
of clinician assessment of hemodynamics in
20. Zema MJ, Restivo B, Sos T, Sniderman KW, ambulatory patients with systolic heart failure. Am
advanced heart failure: the ESCAPE trial. Circ
Kline S. Left ventricular dysfunction–bedside Val- Heart J 2017;183:102–7.
Heart Fail 2008;1:170–7.
salva manoeuvre. Br Heart J 1980;44:560–9. 33. Arena R, Sietsema KE. Cardiopulmonary exer-
8. Butman SM, Ewy GA, Standen JR, Kern KB,
21. Gorlin R, Knowles JH, Storey CF. The Valsalva cise testing in the clinical evaluation of patients
Hahn E. Bedside cardiovascular examination in
maneuver as a test of cardiac function; pathologic with heart and lung disease. Circulation 2011;123:
patients with severe chronic heart failure: impor-
physiology and clinical significance. Am J Med 668–80.
tance of rest or inducible jugular venous disten-
1957;22:197–212. 34. Handa A, Agarwal R. Allergic bronchopulmo-
sion. J Am Coll Cardiol 1993;22:968–74.
nary aspergillosis causing bendopnea. Lung India
9. Cook DJ, Simel DL. The rational clinical exami- 22. McIntyre KM, Vita JA, Lambrew CT, Freeman J,
2017;34:304–5.
nation. Does this patient have abnormal central Loscalzo J. A noninvasive method of predicting
venous pressure? JAMA 1996;275:630–4. pulmonary-capillary wedge pressure. N Engl J 35. Stevenson LW, Perloff JK. The limited reli-
Med 1992;327:1715–20. ability of physical signs for estimating hemody-
10. From AM, Lam CS, Pitta SR, et al. Bedside namics in chronic heart failure. JAMA 1989;261:
assessment of cardiac hemodynamics: the impact 23. Givertz MM, Slawsky MT, Moraes DL,
884–8.
of noninvasive testing and examiner experience. McIntyre KM, Colucci WS. Noninvasive determi-
nation of pulmonary artery wedge pressure in 36. Chakko S, Woska D, Martinez H, et al. Clinical,
Am J Med 2011;124:1051–7.
patients with chronic heart failure. Am J Cardiol radiographic, and hemodynamic correlations in
11. Shah MR, O’Connor CM, Sopko G, Hasselblad V, 2001;87:1213–5, A7. chronic congestive heart failure: conflicting results
Califf RM, Stevenson LW. Evaluation Study of may lead to inappropriate care. Am J Med 1991;
Congestive Heart Failure and Pulmonary Artery 24. Sharma GV, Woods PA, Lambrew CT, et al. 90:353–9.
Catheterization Effectiveness (ESCAPE): design Evaluation of a noninvasive system for deter-
mining left ventricular filling pressure. Arch Intern 37. Caldentey G, Khairy P, Roy D, et al. Prognostic
and rationale. Am Heart J 2001;141:528–35.
Med 2002;162:2084–8. value of the physical examination in patients with
12. Drazner MH, Rame JE, Stevenson LW, Dries DL. heart failure and atrial fibrillation: insights from
Prognostic importance of elevated jugular venous 25. Schmidt DE, Shah PK. Accurate detection of the AF-CHF trial (Atrial Fibrillation and Chronic
pressure and a third heart sound in patients with elevated left ventricular filling pressure by a Heart Failure). J Am Coll Cardiol HF 2014;2:15–23.
heart failure. N Engl J Med 2001;345:574–81. simplified bedside application of the Valsalva
38. Mahdyoon H, Klein R, Eyler W, Lakier JB,
maneuver. Am J Cardiol 1993;71:462–5.
13. Drazner MH, Rame JE, Dries DL. Third heart Chakko SC, Gheorghiade M. Radiographic pulmo-
sound and elevated jugular venous pressure as 26. Bernardi L, Saviolo R, Spodick DH. Do hemo- nary congestion in end-stage congestive heart
markers of the subsequent development of heart dynamic responses to the valsalva maneuver failure. Am J Cardiol 1989;63:625–7.
JACC: HEART FAILURE VOL. -, NO. -, 2018 Thibodeau and Drazner 9
- 2018:-–- Clinical Examination in Heart Failure

39. Yancy CW, Jessup M, Bozkurt B, et al. 2017 between right and left-sided filling pressures in 45. Grodin JL, Drazner MH, Dupont M, et al.
ACC/AHA/HFSA focused update of the 2013 ACCF/ 1000 patients with advanced heart failure. J Heart A disproportionate elevation in right ventricular
AHA guideline for the management of heart fail- Lung Transplant 1999;18:1126–32. filling pressure, in relation to left ventricular filling
ure: a report of the American College of Cardiol- pressure, is associated with renal impairment and
42. Drazner MH, Prasad A, Ayers C, et al. The
ogy/American Heart Association Task Force on increased mortality in advanced decompensated
relationship of right- and left-sided filling pres-
Clinical Practice Guidelines and the Heart Failure heart failure. Am Heart J 2015;169:806–12.
sures in patients with heart failure and a preserved
Society of America. J Am Coll Cardiol 2017;70:
ejection fraction. Circ Heart Fail 2010;3:202–6. 46. Drazner MH, Velez-Martinez M, Ayers CR,
776–803.
et al. Relationship of right- to left-sided ventric-
43. Drazner MH, Brown RN, Kaiser PA, et al.
40. Felker GM, Anstrom KJ, Adams KF, et al. Ef- ular filling pressures in advanced heart failure:
fect of natriuretic peptide-guided therapy on Relationship of right- and left-sided filling pres-
insights from the ESCAPE trial. Circ Heart Fail
hospitalization or cardiovascular mortality in high- sures in patients with advanced heart failure: a 14-
2013;6:264–70.
risk patients with heart failure and reduced ejec- year multi-institutional analysis. J Heart Lung
tion fraction: a randomized clinical trial. JAMA Transplant 2012;31:67–72.
2017;318:713–20. 44. Campbell P, Drazner MH, Kato M, et al. KEY WORDS bendopnea, clinical
41. Drazner MH, Hamilton MA, Fonarow G, Mismatch of right- and left-sided filling pressures examination, hemodynamics, jugular venous
Creaser J, Flavell C, Stevenson LW. Relationship in chronic heart failure. J Card Fail 2011;17:561–8. pressure, prognosis