Nuggets, Pearls, and Vignettes of Master Heart Failure Clinicians

The Physical Examination in Heart Failure—Part II

“…Of course, the timing of the 2 components of S 2 (aortic [A 2 ] and P 2 ) during respiration provides a bedside impression whether a patient has left or right bundle branch block, in addition to the well‐appreciated bedside assessment for a hemodynamically significant atrial septal defect. Using the method reported by Bourge, 2 auscultation of P 2 can provide a reasonable estimation of pulmonary artery systolic pressure (Figure 2). Pulmonic artery systolic pressure moves in concert with LV filling pressure in the absence of interpositioned disorders (mitral stenosis, pulmonary disease).…”

“…As noted in Figure 2, the elevation of pulmonary artery pressure is then directly related to the distance the 2 components of S 2 are heard from the left second intercostal space. The application of this method requires hearing both components of S 2 and reasonable chest anatomy 2 …”

“…It is widely appreciated that gallop sounds have enormous pathophysiologic and prognostic significance 2–5 . As the failing heart evolves from hypertrophy and/or diastolic dysfunction to ventricular systolic dysfunction with volume overload, the accompanying gallop pattern often goes from S 4 , to combined S 4 and S 3 , to S 3 gallop alone.…”

“…A low cardiac output with limb hypoperfusion will render a pallor, sometimes a near‐cyanotic hue, coolness, and moistness (“cool and clammy”) to the skin. Varying degrees of these findings, along with other signs of systemic hypoperfusion (impaired mentation, reduced urine output), assist the clinician in choosing proper pharmacotherapy and interventions needed to manage the patient's threatening clinical condition 2 …”

“…Measuring heart rate during walking has been used for decades to determine whether ventricular rate is adequately controlled during atrial fibrillation. Prompting the patient to talk while walking evokes an additional stress challenge to more aggressively and efficiently assess physical capacity and reserve 2 …”