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June 4, 1997, Vol 277, No. 21 >
ARTICLE | June 4, 1997

Can the Clinical Examination Diagnose Left-Sided Heart Failure in Adults? FREE

Robert G. Badgett, MD; Catherine R. Lucey, MD; Cynthia D. Mulrow, MD, MSc
[+] Author Affiliations

Reprints: Robert G. Badgett, MD, Division of General Medicine, Department of Medicine, University of Texas Health Science Center, 4200 Floyd Curl Dr, San Antonio, TX 78284-7879 (e-mail: Badgett@uthscsa.edu).

The Rational Clinical Examination section editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor (West), JAMA.


JAMA. 1997;277(21):1712-1719. doi:10.1001/jama.1997.03540450068038
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Article
References

We systematically reviewed the literature to ascertain how well clinicians determine the probability and type of left-sided heart failure in their patients. Left-sided heart failure is characterized by decreased left ventricular ejection fraction or increased filling pressure. The type of heart failure determines optimal treatment. Systolic dysfunction exists when ejection fraction is reduced. Diastolic dysfunction is presumed to be present when filling pressure is increased with a normal ejection fraction and without another explanatory diagnosis. Many findings are associated with heart failure, and wide variation exists in clinicians' ability to detect these findings. The best findings for detecting increased filling pressure are jugular venous distention and radiographic redistribution. The best findings for detecting systolic dysfunction are abnormal apical impulse, radiographic cardiomegaly, and q waves or left bundle branch block on an electrocardiogram. Diastolic dysfunction is especially difficult to diagnose, but is associated with an elevated blood pressure during heart failure.

REFERENCES

1 +
The SOLVD Investigators.  Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions . N Engl J Med . 1992;;327:685-691.
2 +
The role of revascularization. In: Konstam M, Dracup K, Baker D, et al, eds. Heart Failure: Evaluation and Care of Patients With Left-Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994:67-77. Clinical Practice Guideline 11.
3 +
Bonow RO, Udelson JE.  Left ventricular diastolic dysfunction as a cause of congestive heart failure . Ann Intern Med . 1992;;117:502-510.
4 +
Gaasch WH.  Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction . JAMA . 1994;;271:1276-1280.
5 +
Holleman DR Jr, Simel DL.  Does the clinical examination predict airflow limitation? JAMA . 1995;;273:313-319.
6 +
Mulrow CD, Lucey CR, Farnett LE.  Discriminating causes of dyspnea through the clinical examination . J Gen Intern Med . 1993;;8:383-392.
7 +
Hutcheon D, Nemeth E, Quinlan D.  The role of furosemide alone and in combination with digoxin in the relief of symptoms of congestive heart failure . J Clin Pharmacol . 1980;;20:59-68.
8 +
Guyatt GH.  The treatment of heart failure . Drugs . 1986;;32:538-568.
9 +
Braunwald E.  Pathophysiology of heart failure . In: Braunwald E. Heart Disease . Philadelphia, Pa: WB Saunders Co 1992;:393.
10 +
Eichna LW.  Circulatory congestion and heart failure . Circulation . 1960;;22:864-886.
11 +
Braunwald E, Ross J.  The ventricular end-diastolic pressure . Am J Med . 1963;;34:147-150.
12 +
Harlan R, Oberman A, Grimm R, Rosati RA.  Chronic congestive heart failure in coronary artery disease . Ann Intern Med . 1977;;86:132-136.
13 +
Chakko S, Woska D, Martinez H, et al.  Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure . Am J Med . 1991;;90:353-359.
14 +
Butman SM, Ewy GA, Standen JR, Kern KB, Hahn E.  Bedside cardiovascular examination in patients with severe chronic heart failure . J Am Coll Cardiol . 1993;;22:968-974.
15 +
Stevenson LW, Perloff JK.  The limited reliability of physical signs for estimating hemodynamics in chronic heart failure . JAMA . 1989;;261:884-888.
16 +
Pharmacologic management. In: Konstam M, Dracup K, Baker D, et al, eds. Heart Failure: Evaluation and Care of Patients With Left-Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994:49-66. Clinical Practice Guideline 11.
17 +
Badgett RG, Mulrow CD, Ramirez G, Otto PM.  How well can the chest radiograph diagnose left ventricular dysfunction? J Gen Intern Med . 1996;;11:625-634.
18 +
Carlson KJ, Lee DC-S, Goroll AH, Leahy M, Johnson RA.  An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients . J Chronic Dis . 1985;;38:733-739.
19 +
Forrester JS, Diamond GA, Swan HJC.  Correlative classification of clinical and hemodynamic function after myocardial infarction . Am J Cardiol . 1977;;39:137-145.
20 +
Forrester JS, Diamond G, Chatterjee K, Swan HJC.  Medical therapy of acute myocardial infarction by application of hemodynamic subsets . N Engl J Med . 1976;;295:1356-1362.
21 +
Fein AM, Goldberg SK, Walkenstein MD, Dershaw B, Braitman L, Lippman ML.  Is pulmonary artery catheterization necessary for the diagnosis of pulmonary edema? Am Rev Respir Dis . 1984;;129:1006-1009.
22 +
Tuchschmidt J, Sharma OP.  Impact of hemodynamic monitoring in a medical intensive care unit . Crit Care Med . 1987;;15:840-843.
23 +
Eisenberg PR, Jaffe AS, Schuster DP.  Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients . Crit Care Med . 1984;;12:549-553.
24 +
Connors AF, McMaffree DR, Gray BA.  Evaluation of right-heart catheterization in the critically ill patient without acute myocardial infarction . N Engl J Med . 1983;;308:263-267.
25 +
Connors AF, Dawson NV, Shaw PK, Montenegro HD, Nara AR, Martin L.  Hemodynamic status in critically ill patients with and without acute heart disease . Chest . 1990;;98:1200-1206.
26 +
Steingrub JS, Celoria G, Vickers-Lahti M, Teres D, Bria W.  Therapeutic impact of pulmonary artery catheterization in a medical/surgical ICU . Chest . 1991;;99:1451-1455.
27 +
Celoria G, Steingrub JS, Vickers-Lahti M, et al.  Clinical assessment of hemodynamic values in two surgical intensive care units . Arch Surg . 1990;;125:1036-1039.
28 +
Rihal CS, Davis KB, Kennedy JW, Gersh BJ.  The utility of clinical, electrocardiographic, and roentgenographic variables in the prediction of left ventricular function . Am J Cardiol . 1995;;75:220-223.
29 +
Eagle KA, Quertermous T, Singer DE, et al.  Left ventricular ejection fraction: physician estimates compared with gated blood pool scan measurements . Arch Intern Med . 1988;;148:882-885.
30 +
Mattleman SJ, Hakki A-H, Iskandrian AS, Segal BL, Kane SA.  Reliability of bedside evaluation in determining left ventricular function . J Am Coll Cardiol . 1983;;1:417-420.
31 +
Ostojic MC, Young JB, Hess KR.  Prediction of left ventricular ejection fraction using a unique method of chest x-ray and ECG analysis . Am Heart J . 1989;;117:590-598.
32 +
Cease KB, Nicklas JM.  Prediction of left ventricular ejection fraction using simple quantitative clinical information . Am J Med . 1986;;81:429-436.
33 +
Gadsbøll N, Høilund-Carlsen PF, Nielsen GG, Bernig J, Bruun NE, Hein E.  Interobserver agreement and accuracy of bedside estimation of right and left ventricular ejection fraction in acute myocardial infarction . Am J Cardiol . 1989;;63:1301-1307.
34 +
Gadsbøll N, Høilund-Carlsen PF, Nielsen GG, et al.  Symptoms and signs of heart failure in patients with myocardial infarction . Eur Heart J . 1989;;10:1017-1028.
35 +
Jain AP, Gupta OP, Kumar A, Trivedi SK.  Evaluation of clinical variables as predictors of left ventricular function in acute myocardial infarction . J Assoc Physicians India . 1993;;41:17-19.
36 +
Mangschau A, Jonsbu J, Karlson RL.  Congestive heart failure and ejection fraction in acute myocardial infarction . Acta Med Scand . 1986;;220:101-107.
37 +
McNamara RF, Carleen E, Moss AJ, and the Multicenter Postinfarction Research Group.  Estimating left ventricular ejection fraction after myocardial infarction by various clinical parameters . Am J Cardiol . 1988;;62:192-196.
38 +
Sanford CF, Corbett J, Nicod P, et al.  Value of radionuclide ventriculography in the immediate characterization of patients with acute myocardial infarction . Am J Cardiol . 1982;;49:637-644.
39 +
Silver MT, Rose GA, Paul SD, O'Donnell CJ, O'Gara PT, Eagle KA.  A clinical rule to predict preserved left ventricular ejection fraction in patients after myocardial infarction . Ann Intern Med . 1994;;121:750-756.
40 +
Ghali JK, Kadakia S, Cooper RS, Liao Y.  Bedside diagnosis of preserved versus impaired systolic function in heart failure . Am J Cardiol . 1991;;67:1002-1006.
41 +
McDermott MM, Feinglass J, Sy J, Gheorghiade M.  Hospitalized congestive heart failure patients with preserved versus abnormal left ventricular systolic function . Am J Med . 1995;;99:629-635.
42 +
Aguirre FV, Pearson AC, Lewen MK, McCluskey M, Labovitz AJ.  Usefulness of Doppler echocardiography in the diagnosis of congestive heart failure . Am J Cardiol . 1989;;63:1098-1102.
43 +
Aronow WS, Ahn C, Kronzon I.  Prognosis of congestive heart failure in elderly patients with normal versus abnormal left ventricular systolic function associated with coronary artery disease . Am J Cardiol . 1989;;63:1526-1528.
44 +
Bier AJ, Eichacker PQ, Sinoway LI, Terribile SM, Strom JA, Keefe DL.  Acute cardiogenic pulmonary edema . Angiology . 1988;;39:211-217.
45 +
Cocchi A, Zuccala G, Del Sindaco D, et al.  Crosssectional echocardiography: a window on congestive heart failure in the elderly . Aging . 1991;;3:257-262.
46 +
Cohn JN, Johnson G, and the Veterans Administration Cooperative Study Group.  Heart failure with normal ejection fraction: the V-HeFT Study . Circulation . 1990;;81:48-53.
47 +
Dougherty AH, Naccarelli GV, Gray EL, Hicks CH, Goldstein RA.  Congestive heart failure with normal systolic function . Am J Cardiol . 1984;;54:778-782.
48 +
Echeverria HH, Bilsker MS, Myerburg RJ, Kessler KM.  Congestive heart failure: echocardiographic insights . Am J Med . 1983;;75:750-755.
49 +
Takarada A, Kurogane H, Minamiji K, et al.  Congestive heart failure in the elderly: echocardiographic insights . Jpn Circ J . 1992;;56:527-534.
50 +
Wong WF, Gold S, Fukuyama 0, Blanchette PL.  Diastolic dysfunction in elderly patients with congestive heart failure . Am J Cardiol . 1989;;63:1526-1528.
51 +
Zema MJ, Restivo B, Sos T, Sniderman KW, Kline S.  Left ventricular dysfunction: bedside Valsalva manoeuvre . Br Heart J . 1980;;44:560-569.
52 +
Zema MJ, Masters AP, Margouleff D.  Dyspnea: the heart of the lungs? Chest . 1984;;85:59-64.
53 +
Heckerling PS, Weiner SL, Wolfkiel CJ, et al.  Accuracy and reproducibility of precordial percussion and palpation for detecting increased left ventricular end-diastolic volume and mass . JAMA . 1993;;270:1943-1948.
54 +
Raudenbush SW.  Random effects models . In: Cooper H, Hedges LV, eds. The Handbook of Research Data Synthesis . New York, NY: Russell Sage Foundation; 1994;:301-316.
55 +
Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology . 2nd ed. Boston, Mass: Little Brown & Co Inc; 1991;:120.
56 +
Mustchin CP, Tiwari I.  Diagnosing the breathless patient . Lancet . 1982;;2:907-908.
57 +
Schmitt BP, Kushner MS, Weiner SL.  The diagnostic usefulness of the history of the patient with dyspnea . J Gen Intern Med . 1986;;1:386-393.
58 +
Fedullo AL, Swinborne AJ, McGuire-Dunn C.  Complaints of breathlessness in the emergency department . N Y State J Med . 1986;;86:4-6.
59 +
Pauker SG, Kassirer JP.  The threshold approach to clinical decision making . N Engl J Med . 1980;;302:1109-1117.
60 +
Simel DL, Feussner JR, Delong ER, Matchar DB.  Intermediate, indeterminate, and uninterpretable diagnostic tests results . Med Decis Making . 1987;;7:107-114.
61 +
Konstam M, Dracup K, Baker D, et al, eds. Heart Failure: Evaluation and Care of Patients With Left-Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994:2. Clinical Practice Guideline 11.
62 +
Westman EC, Matchar DB, Samsa GP, Mulrow CD, Waugh RA, Feussner JR.  Accuracy and reliability of apical S3 gallop detection . J Gen Intern Med . 1995;;10:455-457.
63 +
Mangione S, Nieman LZ, Gracely E, Kaye D.  The teaching and practice of cardiac auscultation during internal medicine and cardiology training . Ann Intern Med . 1993;;119:47-54.
64 +
St.  Clair EW, Oddone EZ, Waugh RA, Corey R, Feussner JR. Assessing housestaff diagnostic skills using a cardiology patient simulator . Ann Intern Med . 1992;;117:751-756.
65 +
Landis JR, Koch GG.  The measurement of observer agreement for categorical data . Biometrics . 1977;;33:159-174.
66 +
Reeves RA.  Does this patient have hypertension? JAMA . 1995;;273:1211-1218.
67 +
Cook DJ, Simel DL.  Does this patient have abnormal central venous pressure? JAMA . 1996;;275:630-634.
68 +
Conn RD, Cole JS.  The cardiac apex impulse . Ann Intern Med . 1971;;75:185-191.
69 +
Eilen SD, Crawford MH, O'Rourke RA.  Accuracy of precordial palpation for detecting increased left ventricular volume . Ann Intern Med . 1983;;99:628-630.
70 +
Badgett RG, Tanaka DJ, Hunt DK, et al.  Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone? Am J Med . 1993;;94:188-196.
71 +
Bates B, Bickley LS, Hoekelman RA. A Guide to Physical Examination and History Taking . 6th ed. Philadelphia, Pa: JB Lippincott; 1995;:286.
72 +
Bethel HJN, Nixon PGF.  Examination of the heart in supine and left lateral positions . Br Heart J . 1973;;35:902-907.
73 +
Glover L, Baxley WA.  A quantitative evaluation of heart size measurements from chest roentgenograms . Circulation . 1973;;47:1289-1296.
74 +
Chikos PM, Figley MM, Fisher L.  Correlation between chest films and angiographic assessment of left ventricular size . AJR Am J Roentgenol . 1977;;128:367-373.
75 +
Danzer CS.  The cardiothoracic ratio . Am J Med Sci . 1919;;157:513-521.
76 +
Feild BJ, Russell RO, Moraski RE, et al.  Left ventricular size and function and heart size in the year following myocardial infarction . Circulation . 1974;;50:331.
77 +
Comeau WJ, White PD.  A critical analysis of standard methods of estimating heart size from roentgen measurements . Am J Roentgenol Rad Ther . 1942;;47:665-677.
78 +
Milne ENC, Pistolesi ENC, Miniati M, Giuntini C.  The radiologic distinction of cardiogenic and noncardiogenic edema . AJR Am J Roentgenol . 1985;;144:879-894.
79 +
Miniati M, Pistolesi M, Paoletti P, et al.  Objective radiographic criteria to differentiate cardiac, renal, and injury lung edema . Invest Radiol . 1988;;23:433-440.
80 +
Norgaard TJ, Gjorup T, Brems-Dalgaard E, Hartelius H, Grun B.  Interobserver variation in the detection of pulmonary venous hypertension in chest radiographs . Eur J Radiol . 1990;;11:203-206.
81 +
Simon M.  The pulmonary vessels in incipient left ventricular decompensation . Circulation . 1961;;24:185-190.
82 +
Burko H, Carwell G, Newman E.  Size, location, and gravitational changes of normal upper lobe pulmonary veins . AJR Am J Roentgenol . 1971;;111:687-689.
83 +
Steiner RM, Levin DC.  Radiology of the heart . In: Braunwald E, ed. Heart Disease . Philadelphia, Pa: WB Saunders Co; 1992;:213.
84 +
Perloff JK, Silverman ME. Physical Examination of the Heart and Circulation [cassette tape]. Bethesda, Md: American College of Cardiology Extended Learning; 1984;.
85 +
Tavel ME. Heart Sounds and Murmurs [cassette tape]. Chicago, Ill: Year Book Medical Publishers Inc; 1973;.
86 +
Tilkian AG, Conover MB. Understanding Heart Sounds and Murmurs [cassette tape/book]. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1984;.
87 +
Harvey WP, Canfield DC. Clinical Auscultation of the Cardiovascular System [cassette tape]. Newton, NJ: Laennec Publishing Company; 1989;.
88 +
Willis PW.  Inspection and palpation of the precordium . In: Hurst JW, Schlant RC, Rackley CE, Sommenblick EH, Wenger NK, eds. The Heart, Arteries, and Veins . New York, NY: McGraw-Hill Book Co; 1990;:165.
89 +
Gillespie ND, McNeil G, Pringle T, Ogston S, Struthers AD, Gillespie SD.  Cross sectional study of contribution of clinical assessment and simple cardiac investigations in patients admitted with acute dyspnea . BMJ . 1997;;314:936-940.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
The SOLVD Investigators.  Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions . N Engl J Med . 1992;;327:685-691.
2 +
The role of revascularization. In: Konstam M, Dracup K, Baker D, et al, eds. Heart Failure: Evaluation and Care of Patients With Left-Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994:67-77. Clinical Practice Guideline 11.
3 +
Bonow RO, Udelson JE.  Left ventricular diastolic dysfunction as a cause of congestive heart failure . Ann Intern Med . 1992;;117:502-510.
4 +
Gaasch WH.  Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction . JAMA . 1994;;271:1276-1280.
5 +
Holleman DR Jr, Simel DL.  Does the clinical examination predict airflow limitation? JAMA . 1995;;273:313-319.
6 +
Mulrow CD, Lucey CR, Farnett LE.  Discriminating causes of dyspnea through the clinical examination . J Gen Intern Med . 1993;;8:383-392.
7 +
Hutcheon D, Nemeth E, Quinlan D.  The role of furosemide alone and in combination with digoxin in the relief of symptoms of congestive heart failure . J Clin Pharmacol . 1980;;20:59-68.
8 +
Guyatt GH.  The treatment of heart failure . Drugs . 1986;;32:538-568.
9 +
Braunwald E.  Pathophysiology of heart failure . In: Braunwald E. Heart Disease . Philadelphia, Pa: WB Saunders Co 1992;:393.
10 +
Eichna LW.  Circulatory congestion and heart failure . Circulation . 1960;;22:864-886.
11 +
Braunwald E, Ross J.  The ventricular end-diastolic pressure . Am J Med . 1963;;34:147-150.
12 +
Harlan R, Oberman A, Grimm R, Rosati RA.  Chronic congestive heart failure in coronary artery disease . Ann Intern Med . 1977;;86:132-136.
13 +
Chakko S, Woska D, Martinez H, et al.  Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure . Am J Med . 1991;;90:353-359.
14 +
Butman SM, Ewy GA, Standen JR, Kern KB, Hahn E.  Bedside cardiovascular examination in patients with severe chronic heart failure . J Am Coll Cardiol . 1993;;22:968-974.
15 +
Stevenson LW, Perloff JK.  The limited reliability of physical signs for estimating hemodynamics in chronic heart failure . JAMA . 1989;;261:884-888.
16 +
Pharmacologic management. In: Konstam M, Dracup K, Baker D, et al, eds. Heart Failure: Evaluation and Care of Patients With Left-Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994:49-66. Clinical Practice Guideline 11.
17 +
Badgett RG, Mulrow CD, Ramirez G, Otto PM.  How well can the chest radiograph diagnose left ventricular dysfunction? J Gen Intern Med . 1996;;11:625-634.
18 +
Carlson KJ, Lee DC-S, Goroll AH, Leahy M, Johnson RA.  An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients . J Chronic Dis . 1985;;38:733-739.
19 +
Forrester JS, Diamond GA, Swan HJC.  Correlative classification of clinical and hemodynamic function after myocardial infarction . Am J Cardiol . 1977;;39:137-145.
20 +
Forrester JS, Diamond G, Chatterjee K, Swan HJC.  Medical therapy of acute myocardial infarction by application of hemodynamic subsets . N Engl J Med . 1976;;295:1356-1362.
21 +
Fein AM, Goldberg SK, Walkenstein MD, Dershaw B, Braitman L, Lippman ML.  Is pulmonary artery catheterization necessary for the diagnosis of pulmonary edema? Am Rev Respir Dis . 1984;;129:1006-1009.
22 +
Tuchschmidt J, Sharma OP.  Impact of hemodynamic monitoring in a medical intensive care unit . Crit Care Med . 1987;;15:840-843.
23 +
Eisenberg PR, Jaffe AS, Schuster DP.  Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients . Crit Care Med . 1984;;12:549-553.
24 +
Connors AF, McMaffree DR, Gray BA.  Evaluation of right-heart catheterization in the critically ill patient without acute myocardial infarction . N Engl J Med . 1983;;308:263-267.
25 +
Connors AF, Dawson NV, Shaw PK, Montenegro HD, Nara AR, Martin L.  Hemodynamic status in critically ill patients with and without acute heart disease . Chest . 1990;;98:1200-1206.
26 +
Steingrub JS, Celoria G, Vickers-Lahti M, Teres D, Bria W.  Therapeutic impact of pulmonary artery catheterization in a medical/surgical ICU . Chest . 1991;;99:1451-1455.
27 +
Celoria G, Steingrub JS, Vickers-Lahti M, et al.  Clinical assessment of hemodynamic values in two surgical intensive care units . Arch Surg . 1990;;125:1036-1039.
28 +
Rihal CS, Davis KB, Kennedy JW, Gersh BJ.  The utility of clinical, electrocardiographic, and roentgenographic variables in the prediction of left ventricular function . Am J Cardiol . 1995;;75:220-223.
29 +
Eagle KA, Quertermous T, Singer DE, et al.  Left ventricular ejection fraction: physician estimates compared with gated blood pool scan measurements . Arch Intern Med . 1988;;148:882-885.
30 +
Mattleman SJ, Hakki A-H, Iskandrian AS, Segal BL, Kane SA.  Reliability of bedside evaluation in determining left ventricular function . J Am Coll Cardiol . 1983;;1:417-420.
31 +
Ostojic MC, Young JB, Hess KR.  Prediction of left ventricular ejection fraction using a unique method of chest x-ray and ECG analysis . Am Heart J . 1989;;117:590-598.
32 +
Cease KB, Nicklas JM.  Prediction of left ventricular ejection fraction using simple quantitative clinical information . Am J Med . 1986;;81:429-436.
33 +
Gadsbøll N, Høilund-Carlsen PF, Nielsen GG, Bernig J, Bruun NE, Hein E.  Interobserver agreement and accuracy of bedside estimation of right and left ventricular ejection fraction in acute myocardial infarction . Am J Cardiol . 1989;;63:1301-1307.
34 +
Gadsbøll N, Høilund-Carlsen PF, Nielsen GG, et al.  Symptoms and signs of heart failure in patients with myocardial infarction . Eur Heart J . 1989;;10:1017-1028.
35 +
Jain AP, Gupta OP, Kumar A, Trivedi SK.  Evaluation of clinical variables as predictors of left ventricular function in acute myocardial infarction . J Assoc Physicians India . 1993;;41:17-19.
36 +
Mangschau A, Jonsbu J, Karlson RL.  Congestive heart failure and ejection fraction in acute myocardial infarction . Acta Med Scand . 1986;;220:101-107.
37 +
McNamara RF, Carleen E, Moss AJ, and the Multicenter Postinfarction Research Group.  Estimating left ventricular ejection fraction after myocardial infarction by various clinical parameters . Am J Cardiol . 1988;;62:192-196.
38 +
Sanford CF, Corbett J, Nicod P, et al.  Value of radionuclide ventriculography in the immediate characterization of patients with acute myocardial infarction . Am J Cardiol . 1982;;49:637-644.
39 +
Silver MT, Rose GA, Paul SD, O'Donnell CJ, O'Gara PT, Eagle KA.  A clinical rule to predict preserved left ventricular ejection fraction in patients after myocardial infarction . Ann Intern Med . 1994;;121:750-756.
40 +
Ghali JK, Kadakia S, Cooper RS, Liao Y.  Bedside diagnosis of preserved versus impaired systolic function in heart failure . Am J Cardiol . 1991;;67:1002-1006.
41 +
McDermott MM, Feinglass J, Sy J, Gheorghiade M.  Hospitalized congestive heart failure patients with preserved versus abnormal left ventricular systolic function . Am J Med . 1995;;99:629-635.
42 +
Aguirre FV, Pearson AC, Lewen MK, McCluskey M, Labovitz AJ.  Usefulness of Doppler echocardiography in the diagnosis of congestive heart failure . Am J Cardiol . 1989;;63:1098-1102.
43 +
Aronow WS, Ahn C, Kronzon I.  Prognosis of congestive heart failure in elderly patients with normal versus abnormal left ventricular systolic function associated with coronary artery disease . Am J Cardiol . 1989;;63:1526-1528.
44 +
Bier AJ, Eichacker PQ, Sinoway LI, Terribile SM, Strom JA, Keefe DL.  Acute cardiogenic pulmonary edema . Angiology . 1988;;39:211-217.
45 +
Cocchi A, Zuccala G, Del Sindaco D, et al.  Crosssectional echocardiography: a window on congestive heart failure in the elderly . Aging . 1991;;3:257-262.
46 +
Cohn JN, Johnson G, and the Veterans Administration Cooperative Study Group.  Heart failure with normal ejection fraction: the V-HeFT Study . Circulation . 1990;;81:48-53.
47 +
Dougherty AH, Naccarelli GV, Gray EL, Hicks CH, Goldstein RA.  Congestive heart failure with normal systolic function . Am J Cardiol . 1984;;54:778-782.
48 +
Echeverria HH, Bilsker MS, Myerburg RJ, Kessler KM.  Congestive heart failure: echocardiographic insights . Am J Med . 1983;;75:750-755.
49 +
Takarada A, Kurogane H, Minamiji K, et al.  Congestive heart failure in the elderly: echocardiographic insights . Jpn Circ J . 1992;;56:527-534.
50 +
Wong WF, Gold S, Fukuyama 0, Blanchette PL.  Diastolic dysfunction in elderly patients with congestive heart failure . Am J Cardiol . 1989;;63:1526-1528.
51 +
Zema MJ, Restivo B, Sos T, Sniderman KW, Kline S.  Left ventricular dysfunction: bedside Valsalva manoeuvre . Br Heart J . 1980;;44:560-569.
52 +
Zema MJ, Masters AP, Margouleff D.  Dyspnea: the heart of the lungs? Chest . 1984;;85:59-64.
53 +
Heckerling PS, Weiner SL, Wolfkiel CJ, et al.  Accuracy and reproducibility of precordial percussion and palpation for detecting increased left ventricular end-diastolic volume and mass . JAMA . 1993;;270:1943-1948.
54 +
Raudenbush SW.  Random effects models . In: Cooper H, Hedges LV, eds. The Handbook of Research Data Synthesis . New York, NY: Russell Sage Foundation; 1994;:301-316.
55 +
Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology . 2nd ed. Boston, Mass: Little Brown & Co Inc; 1991;:120.
56 +
Mustchin CP, Tiwari I.  Diagnosing the breathless patient . Lancet . 1982;;2:907-908.
57 +
Schmitt BP, Kushner MS, Weiner SL.  The diagnostic usefulness of the history of the patient with dyspnea . J Gen Intern Med . 1986;;1:386-393.
58 +
Fedullo AL, Swinborne AJ, McGuire-Dunn C.  Complaints of breathlessness in the emergency department . N Y State J Med . 1986;;86:4-6.
59 +
Pauker SG, Kassirer JP.  The threshold approach to clinical decision making . N Engl J Med . 1980;;302:1109-1117.
60 +
Simel DL, Feussner JR, Delong ER, Matchar DB.  Intermediate, indeterminate, and uninterpretable diagnostic tests results . Med Decis Making . 1987;;7:107-114.
61 +
Konstam M, Dracup K, Baker D, et al, eds. Heart Failure: Evaluation and Care of Patients With Left-Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994:2. Clinical Practice Guideline 11.
62 +
Westman EC, Matchar DB, Samsa GP, Mulrow CD, Waugh RA, Feussner JR.  Accuracy and reliability of apical S3 gallop detection . J Gen Intern Med . 1995;;10:455-457.
63 +
Mangione S, Nieman LZ, Gracely E, Kaye D.  The teaching and practice of cardiac auscultation during internal medicine and cardiology training . Ann Intern Med . 1993;;119:47-54.
64 +
St.  Clair EW, Oddone EZ, Waugh RA, Corey R, Feussner JR. Assessing housestaff diagnostic skills using a cardiology patient simulator . Ann Intern Med . 1992;;117:751-756.
65 +
Landis JR, Koch GG.  The measurement of observer agreement for categorical data . Biometrics . 1977;;33:159-174.
66 +
Reeves RA.  Does this patient have hypertension? JAMA . 1995;;273:1211-1218.
67 +
Cook DJ, Simel DL.  Does this patient have abnormal central venous pressure? JAMA . 1996;;275:630-634.
68 +
Conn RD, Cole JS.  The cardiac apex impulse . Ann Intern Med . 1971;;75:185-191.
69 +
Eilen SD, Crawford MH, O'Rourke RA.  Accuracy of precordial palpation for detecting increased left ventricular volume . Ann Intern Med . 1983;;99:628-630.
70 +
Badgett RG, Tanaka DJ, Hunt DK, et al.  Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone? Am J Med . 1993;;94:188-196.
71 +
Bates B, Bickley LS, Hoekelman RA. A Guide to Physical Examination and History Taking . 6th ed. Philadelphia, Pa: JB Lippincott; 1995;:286.
72 +
Bethel HJN, Nixon PGF.  Examination of the heart in supine and left lateral positions . Br Heart J . 1973;;35:902-907.
73 +
Glover L, Baxley WA.  A quantitative evaluation of heart size measurements from chest roentgenograms . Circulation . 1973;;47:1289-1296.
74 +
Chikos PM, Figley MM, Fisher L.  Correlation between chest films and angiographic assessment of left ventricular size . AJR Am J Roentgenol . 1977;;128:367-373.
75 +
Danzer CS.  The cardiothoracic ratio . Am J Med Sci . 1919;;157:513-521.
76 +
Feild BJ, Russell RO, Moraski RE, et al.  Left ventricular size and function and heart size in the year following myocardial infarction . Circulation . 1974;;50:331.
77 +
Comeau WJ, White PD.  A critical analysis of standard methods of estimating heart size from roentgen measurements . Am J Roentgenol Rad Ther . 1942;;47:665-677.
78 +
Milne ENC, Pistolesi ENC, Miniati M, Giuntini C.  The radiologic distinction of cardiogenic and noncardiogenic edema . AJR Am J Roentgenol . 1985;;144:879-894.
79 +
Miniati M, Pistolesi M, Paoletti P, et al.  Objective radiographic criteria to differentiate cardiac, renal, and injury lung edema . Invest Radiol . 1988;;23:433-440.
80 +
Norgaard TJ, Gjorup T, Brems-Dalgaard E, Hartelius H, Grun B.  Interobserver variation in the detection of pulmonary venous hypertension in chest radiographs . Eur J Radiol . 1990;;11:203-206.
81 +
Simon M.  The pulmonary vessels in incipient left ventricular decompensation . Circulation . 1961;;24:185-190.
82 +
Burko H, Carwell G, Newman E.  Size, location, and gravitational changes of normal upper lobe pulmonary veins . AJR Am J Roentgenol . 1971;;111:687-689.
83 +
Steiner RM, Levin DC.  Radiology of the heart . In: Braunwald E, ed. Heart Disease . Philadelphia, Pa: WB Saunders Co; 1992;:213.
84 +
Perloff JK, Silverman ME. Physical Examination of the Heart and Circulation [cassette tape]. Bethesda, Md: American College of Cardiology Extended Learning; 1984;.
85 +
Tavel ME. Heart Sounds and Murmurs [cassette tape]. Chicago, Ill: Year Book Medical Publishers Inc; 1973;.
86 +
Tilkian AG, Conover MB. Understanding Heart Sounds and Murmurs [cassette tape/book]. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1984;.
87 +
Harvey WP, Canfield DC. Clinical Auscultation of the Cardiovascular System [cassette tape]. Newton, NJ: Laennec Publishing Company; 1989;.
88 +
Willis PW.  Inspection and palpation of the precordium . In: Hurst JW, Schlant RC, Rackley CE, Sommenblick EH, Wenger NK, eds. The Heart, Arteries, and Veins . New York, NY: McGraw-Hill Book Co; 1990;:165.
89 +
Gillespie ND, McNeil G, Pringle T, Ogston S, Struthers AD, Gillespie SD.  Cross sectional study of contribution of clinical assessment and simple cardiac investigations in patients admitted with acute dyspnea . BMJ . 1997;;314:936-940.

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To understand the clinical management of acute heart failure syndromes.
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Compression-Only CPR: Pushing the Science Forward
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BMJ 2010;341:c5893-c1494.
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