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Am Fam Physician. 1998;57(5):1104-1107

The diagnosis and management of left-sided heart failure can be difficult. Badgett and associates reviewed the literature to assess how well clinicians diagnose this condition clinically and to identify clinical findings that may signify decreased ejection fraction, increased filling pressure and systolic or diastolic dysfunction.

Since left-sided heart failure can be defined as decreased ejection fraction or increased filling pressure, patients may fit into one of three categories: those with decreased ejection fraction and normal filling pressure, those with decreased ejection fraction and increased filling pressure, and those with normal ejection fraction and increased filling pressure (diastolic dysfunction). A MEDLINE search was conducted, and 34 studies were found that examined the ability of the clinical findings or clinical examination to predict filling pressure or ejection fraction. Clinical findings were classified as “very helpful,” “somewhat helpful” or “helpful only when present” (see the accompanying table).

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The diagnosis of increased left ventricular filling pressure cannot be made on the basis of a single clinical finding. Radiographic redistribution (also known as cephalization or pulmonary venous hypertension) and jugular venous distention were found to be very helpful findings but are best used to confirm increased filling pressure in a patient with known severe systolic dysfunction. Lack of radiographic redistribution or jugular venous distention, however, does not exclude increased filling pressure. Dyspnea and abnormal vital signs were found to be somewhat helpful in the detection of increased filling pressure. Dependent edema was helpful in making the diagnosis only when present.

Since the detection of increased filling pressure is difficult, the authors suggest that the number of abnormal findings on examination may correlate with a probability of increased filling pressure. In the absence of known severe systolic dysfunction, patients with no more than one abnormal finding are likely to have a normal filling pressure, whereas those with at least three abnormal findings may have increased filling pressure.

Certain clinical findings may help identify patients with an ejection fraction of less than 40 percent. These findings are as follows: cardiomegaly (radiographically determined), abnormal apical impulse, radiographic redistribution, left bundle branch block and anterior Q waves. Tachycardia, decreased blood pressure and a third heart sound may be somewhat helpful findings. Insignificant clinical findings include the patient's age, orthopnea, left ventricular hypertrophy, a history of hypertension and a history of heart failure. Again, patients may be classified as having a high, an indeterminate or a low probability of decreased ejection fraction. A decreased ejection fraction is much more likely if three or more abnormal clinical findings are present. Patients with a low probability of decreased ejection fraction have none of the abnormal clinical findings associated with a decreased ejection fraction.

Distinguishing between diastolic and systolic dysfunction may be aided by the finding of elevated blood pressure during an episode of increased filling pressure. Obesity, lack of tachycardia, absence of smoking and no history of coronary artery disease may be somewhat helpful findings. Patients with a normal heart size are unlikely to have diastolic dysfunction.

The authors conclude that, while it is difficult to clinically diagnose left-sided heart failure, certain findings make such a diagnosis more or less likely.

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