History and physical exam for heart failure

Your medical history includes anything about your past and present health—conditions you used to have or conditions you have now. Tell your doctor about medical problems of any type, including any surgery that you have had. When giving your doctor your medical history, be complete and detailed in your descriptions. Even if an illness is completely gone or does not seem important to you, knowing about that problem may help your doctor diagnose heart failure. In addition, knowing all of your past and present medical problems will help your doctor decide the best way to care for your condition.

As part of your medical history, you should also review with your doctor the medicines that you currently are taking. This is best done by bringing an updated list of the names and dosages of all the medicines that you are taking.

In addition to the medical conditions that you have had or now have, your doctor will want to know about several factors that increase your risk for developing heart failure. Since coronary artery disease (CAD) is the major cause of heart failure, risk factors for heart failure include the major risk factors for CAD, such as smoking, diabetes, high total cholesterol or LDL cholesterol, high blood pressure, advanced age, and being male. Drinking too much alcohol is also a risk factor for heart failure. Your doctor will take into account all of the risk factors you have when trying to determine whether you have heart failure. The more risk factors you have and the more severe they are, the greater your chance of having heart failure.

If other members of your family have developed heart failure at a young age, you may be at risk for developing a genetic form of heart failure. In addition, if several members of your family also have had diseases that are risk factors for heart failure, such as hypertension or diabetes, you may be at increased risk for those diseases, which also increases your risk for developing heart failure.

During a medical history and physical exam, the doctor will ask about symptoms (such as shortness of breath, swelling, and coughing), recent or past illnesses (such as heart attack, viral illness, high blood pressure, and diabetes), physical activity, breathing, sleeping, eating, and other routine activities.

The parts of the physical exam that are most helpful in diagnosing heart failure are:

• Measuring blood pressure and pulse rate.
• Checking the veins in the neck for swelling or evidence of high blood pressure in the veins that return blood to the heart. Swelling or bulging veins may indicate right-sided heart failure or advanced left-sided heart failure.
• Listening to breathing (lung sounds).
• Listening to the heart for murmurs or extra heart sounds.
• Checking the abdomen for swelling caused by fluid buildup and for enlargement or tenderness over the liver.
• Checking the legs and ankles for swelling caused by fluid buildup (edema).
• Measuring body weight.

The physical exam is a regular part of almost any visit for heart problems.

Usually, signs of some underlying heart condition are present, such as high blood pressure or a heart murmur that indicates heart valve disease.

If you have symptoms typical of heart failure, the physical exam may be all that your doctor needs to make the diagnosis. However, you will have additional tests to determine the specific cause and type of heart failure so that you can receive appropriate treatment.

During the history and physical exam, the doctor will look for signs of heart failure, including bubbling or crackling sounds in the chest (pulmonary rales) that are heard through a stethoscope. This indicates fluid buildup in the lungs. The doctor may detect an extra heart sound (called an S3), find that the veins in the neck bulge out, detect a rapid heart rate, or find evidence of fluid buildup (edema) in the extremities. The liver may be enlarged and tender to the touch.

Normal

• Lung and heart sounds are normal, blood pressure is normal, and you have no sign of fluid buildup or swollen veins in the neck.
• You may have further exams or tests to check for other causes of symptoms.

Abnormal findings that suggest heart failure

• High blood pressure (140/90 mm Hg or above) or low blood pressure is present. Low blood pressure could be a sign of late-stage heart failure.
• An irregular heart rate (cardiac arrhythmia)
• A third heart sound (indicating abnormal movement of blood through the heart) is heard. Heart murmurs may or may not be present.
• The impulse normally felt from the lower tip of the heart (apex) is not felt in its normal position on the chest wall, suggesting enlargement of the heart.
• Swollen neck veins or abnormal movement of blood in the neck veins suggest that blood may be backing up in the right ventricle.
• Noises (pulmonary rales) such as bubbling or crackling are heard, which may indicate fluid buildup in the lungs. Your doctor uses a stethoscope to hear these noises while you take deep breaths.
• You have a swollen liver or have pain in the right upper abdomen, loss of appetite, or bloating. This suggests that blood may be backing up into the body.
• You have swelling in your legs, ankles, or feet or in the lower back when you lie down, and it is clearly not caused by another condition. Fluid buildup first occurs during the day and goes away overnight; as heart failure becomes worse, fluid buildup may not go away.

Some people with early symptoms of heart failure have no physical findings.

No single finding on the physical exam indicates heart failure, although a certain collection of symptoms is highly suggestive of both heart failure and the specific cause. The diagnosis depends on the whole picture of physical findings, symptoms, and tests. There are many other causes of the abnormal physical exam findings listed above.

If physical findings and your medical history strongly suggest heart failure, you most likely will have a chest X-ray, an echocardiogram, and electrocardiography to evaluate the heart size, shape, and function and to evaluate the lungs for signs of fluid buildup.

One study showed that a person with heart failure who has elevated jugular vein pressure or a third heart sound has an increased risk of complications, including worsening of heart failure.¹

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Citations

1. Drazner MH, et al. (2001). Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. New England Journal of Medicine, 345(8): 574–581.