3-2-1: 3 exams, 2 minutes, 1 echocardiogram saved

Echocardiography is essential for diagnosing and managing heart failure. It is noninvasive, safe, and relatively inexpensive (unless a patient is uninsured, in which case the outpatient cost can be prohibitive), and the information it provides may not be otherwise attainable. Current guidelines from the American College of Cardiology/American Heart Association recommend echocardiography as the preferred initial imaging modality for diagnosing heart failure; it assesses left ventricular ejection fraction, cardiac chamber size, wall thickness, valvular function, and filling pressures. Of importance, echocardiography enables the clinician to distinguish between heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), a phenotypic distinction that guides therapy and predicts clinical course and complications.

So why use physical examination to make clinical decisions and recommendations without an echocardiogram? In my practice that question comes up not infrequently. Some actual cases come to mind: A 62-year-old woman being treated for hypertension with amlodipine (hint, hint) is concerned about bilateral ankle edema; a 57-year old man with mitral valve prolapse but no history of heart failure, whose wife is dealing with advanced breast cancer, reports shortness of breath when he is trying to fall asleep, but not during exertion (an NT-proBNP was ordered but will not come back until the next day); and a 62-year old woman with a history of myelofibrosis but now with acute myelocytic leukemia accompanied by multiple myeloid sarcomas, including a bulky lesion in her right femoral triangle, is concerned about ipsilateral ankle edema (don't worry, I did order a venous ultrasound). Should I have ordered an echocardiogram for her and for the other patients? In each of these cases, the diagnosis of congestive heart failure should at least be considered.

Welcome to the practice of office-based internal medicine in 2025. Are we duty-bound to obtain the most definitive answer about a serious illness such as congestive heart failure with an echocardiogram even when the pretest probability of that condition is low? Or might we use clinical judgment and clinical examination and manage the patient, and follow the patient, for a while without relying on advanced imaging or technology?

Readers familiar with the irreplaceable “Evidence-Based Physical Diagnosis” by Steven McGee, MD, or those who have been privileged to hear Dr. McGee speak at an ACP annual meeting should now be nodding and smiling in recognition. Dr. McGee lays out physical exam maneuvers that are useful in the type of clinical setting in which many of us work. He presents the diagnostic value of each finding, expressed as likelihood ratios, and, equally important, he describes how each diagnostic maneuver should be performed.

My series of bedside maneuvers for ruling out heart failure in low-probability situations includes three physical exams: jugular venous pressure (JVP), abdominojugular reflux (AJR), and the Valsalva response. All three have sufficiently low negative likelihood ratios, which make them particularly helpful in ruling out heart failure in patients like the ones I described who have a low pretest probability.

For the JVP, I place the patient in a reclined position, low enough so I can visualize the top of the venous column. This is done from the right side because the jugular neck veins on the right side have a direct route to the right atrium (and because every time you examine the patient from the left side, William Osler spins in his grave). I look to see if the venous column at end expiration is less than 3 cm above the sternal angle. If it is, the probability of the patient having an elevated central venous pressure, and therefore right ventricular failure or overload, is reduced considerably. In a patient whose pretest probability of heart failure is low to begin with, this significant reduction in probability takes the likelihood of a cardiac cause for edema to low enough levels where I can be confident that for patients like #1 and #3 above, the edema has another cause.

Then, I will check for the AJR by pressing firmly (30 mm of mercury is the standard) on the patient's abdomen for at least 10 seconds and observe if there is a sustained rise of at least 4 cm vertically of the venous level. If there is not, once again the likelihood of elevated cardiac filling pressures is considerably reduced.

Finally, I check for the Valsalva response, which calls for inflating a blood pressure cuff to 15 cm above the patient's systolic pressure so the Korotkoff sounds are no longer heard, then having the patient perform a Valsalva maneuver for about 20 seconds, which obliterates the Korotkoff sounds, and listening to hear if the Korotkoff sounds reappear after the Valsalva strain has been released. If they do, the likelihood of elevated left heart filling pressure and, in the case of HFrEF, low ejection fraction, is considerably reduced.

I estimate that all three maneuvers can be accomplished in about two minutes, and if all are negative, this provides assurance that heart failure is not the cause of the patient's symptoms. Patient #1 can be taken off amlodipine (or not) and checked again in a few weeks. Patient #2 can be reassured that cardiac failure is not a concern right now, counseled on coping with the stress of his wife's illness, and seen again soon to be sure he is doing all right. For patient #3, a venous ultrasound becomes that much more important now that heart failure is not a likely cause of her edema. All three patients can be managed without an echocardiogram.

The point here is not to disparage echocardiography. Few noninvasive tests are as useful. Rather, the point is that echocardiograms are not always required. In many medical centers, outpatient echocardiograms can take days or weeks to be scheduled, and when the results finally return, they may not answer the specific questions for which the study was ordered. The physical exam, however, does just that, perhaps not with 100% certainty, but with enough certainty to allow the busy clinician to move on knowing that congestive heart failure is unlikely, or at least not likely enough to warrant further testing or intervention. Not a bad outcome for a few minutes of hands-on physical diagnosis. And what else could make the office practice of internal medicine more satisfying?