Utility of History, Physical Examination, Electrocardiogram, and ...

CLINICAL STUDIES 

Utility of History, Physical Examination, 

Electrocardiogram, and Chest Radiograph for 

Differentiating Normal from Decreased Systolic 

Function in Patients with Heart Failure 

James T. Thomas, MD, Russell F. Kelly, MD, Smitha J. Thomas, MBBS, Thomas D. Stamos, MD, 

Khaled Albasha, MD, Joseph E. Parrillo, MD, James E. Calvin, MD 

PURPOSE: To determine whether clinical parameters alone 

can differentiate normal versus decreased systolic left ventricular 

function in patients with heart failure. 

SUBJECTS AND METHODS: Detailed clinical data were collected 

prospectively from 225 consecutive patients who were 

hospitalized with heart failure. Findings in patients with normal 

(ejection fraction 45%) or decreased (ejection fraction 

45%) left ventricular function were compared. 

RESULTS: Systolic function was normal in 104 patients (46%) 

and decreased in 121 patients (54%). Patients with normal 

function were older (mean [ SD] age, 59 13 years vs. 54 

13 years, P 0.007) and more likely to be female (56% vs. 35%, 

P 0.001), obese (body mass index 30 kg/m 2 , 62% vs. 48%, P 

0.04), have marked systolic (160 mm Hg, 50% vs. 27%, P 

0.001) and diastolic (110 mm Hg, 25% vs. 13%, P 0.02) 

hypertension, and use calcium antagonists (34% vs. 14%, P 

0.001). Patients with decreased function were more likely to use 

Congestive heart failure may occur with either normal 

or decreased left ventricular systolic function 

(1– 4). Because management may be different for 

patients with normal or decreased systolic function (1,5), 

determining left ventricular function is important. Currently, 

determination of left ventricular function requires 

specialized testing with echocardiography, radionuclide 

ventriculography, cardiac catheterization with contrast 

ventriculography, or cardiac magnetic resonance imaging, 

but it would be advantageous if physicians could differentiate 

patients with normal systolic function from 

those with decreased function using only clinical parameters. 

Several studies have attempted to identify clinical dif- 

From the Division of Cardiology (JTT, RFK, SJT, TDS, KA, JEC), Cook 

County Hospital; and the Section of Cardiology (RFK, TDS, JEP, JEC), 

Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois. 

Requests for reprints should be addressed to Russell F. Kelly, MD, 

Rush-Presbyterian-St. Luke’s Medical Center, 1725 W. Congress Parkway, 

Suite 407, Chicago, Illinois 60612. 

Manuscript submitted August 11, 2000, and accepted in revised form 

January 4, 2002. 

alcohol (37% vs. 20%, P 0.007), angiotensin-converting enzyme 

(ACE) inhibitors (85% vs. 62%, P 0.001), and digoxin 

(57% vs. 27%, P 0.001); and more likely to have tachycardia 

(51% vs. 32%, P 0.004), rales (89% vs. 80%, P 0.05), electrocardiographic 

left ventricular hypertrophy (42% vs. 22%, 

P 0.002), left atrial abnormality (52% vs. 22%, P 0.001), 

or flow cephalization on chest radiograph (91% vs. 79%, P 

0.02). Only sex, tachycardia, and use of digoxin and ACE inhibitors 

were associated with ventricular function in multivariable 

analysis. However, the sensitivity, specificity, and predictive values 

for all clinical variables were low. 

CONCLUSION: Differences in clinical parameters in heart 

failure patients with decreased versus normal systolic function 

cannot predict systolic function in these patients, supporting 

recommendations that heart failure patients should undergo 

specialized testing to measure ventricular function. Am J Med. 

2002;112:437– 445. 2002 by Excerpta Medica, Inc. 

ferences between heart failure patients who have normal 

or decreased systolic function (6 –9). Most of these studies 

have been retrospective, and the findings have been 

inconsistent and contradictory (7–16). The purpose of 

the present study was to determine whether prospectively 

collected clinical parameters, including results of the history, 

physical examination, electrocardiography, and 

chest radiograph, could differentiate patients with heart 

failure and normal left ventricular systolic function from 

those with decreased function. 

METHODS 

We evaluated consecutive patients admitted to Cook 

County Hospital with the primary diagnosis of congestive 

heart failure during a 4-month period. We prospectively 

collected data on each patient at the time of admission to 

the hospital, including demographic characteristics, coronary 

risk factors, alcohol use, current medications, and 

history of coronary artery disease or chronic renal failure. 

Historical and physical examination data were extracted 

2002 by Excerpta Medica, Inc. 0002-9343/02/$–see front matter 437 

All rights reserved. PII S0002-9343(02)01048-3

from the attending physician’s note (internist or cardiologist) 

from hospital day 1 or 2; whether the attending 

physicians were aware of a patient’s systolic function 

when a note was written is unknown. Recorded symptoms 

included dyspnea at rest, dyspnea with exertion, 

orthopnea, paroxysmal nocturnal dyspnea, angina, and 

nonanginal chest pain. Physical examination findings included 

height, weight, heart rate, systolic and diastolic 

blood pressure, jugular venous distention, hepatojugular 

reflux, rales, wheezing, S 3 and S 4 gallops, and pedal 

edema. Pulse pressure was calculated as systolic minus 

diastolic blood pressure, and body mass index was calculated 

as weight (in kg) divided by height (in m 2 ). Most 

parameters (80%) were recorded in 97% of the patients. 

We assessed whether patients met the Framingham 

criteria for heart failure (17). 

Admission electrocardiograms (ECGs) were assessed 

by a cardiologist who was unaware of other patient data 

for rhythm (recorded as sinus, atrial fibrillation, or other), 

presence of abnormal Q waves, left ventricular hypertrophy 

by the Estes criteria (18), and left atrial abnormality 

(defined as P terminal force in V 1 more negative than 

0.04 ms, or a notched P wave 0.12 s) (19). The admission 

chest radiograph was evaluated by an attending radiologist 

for the presence of cardiomegaly, flow cephalization, 

pleural effusion, and pulmonary edema. 

Left ventricular systolic function was determined by 

echocardiography. All ECGs were performed at Cook 

County Hospital and were interpreted by experienced 

cardiologists who were unaware of the specific clinical 

findings in the patients. Normal systolic function was defined 

as an ejection fraction 45% (20) as assessed by 

visual inspection. Decreased systolic function was defined 

as ejection fraction 45%. Patients were excluded if 

left ventricular function was not measured, and also if 

primary valvular disease was present. Patients with mitral 

or tricuspid regurgitation judged to be a result of heart 

failure, rather than the cause of the condition, were not 

excluded. 

Statistical Analysis 

Chi-squared tests were used to compare categorical variables, 

and two-sided t tests were used for continuous variables. 

The sensitivity, specificity, and positive and negative 

predictive values for normal systolic function were 

calculated for each clinical variable. Multivariate logistic 

regression analysis was also performed, including variables 

with univariate P values 0.10, to identify independent 

predictors of decreased systolic function. Receiver 

operating characteristic curves were constructed for these 

predictors. A sub-analysis was performed in which patients 

with markedly depressed systolic function (ejection 

fraction 30%) were compared with those who had an 

ejection fraction 30%. A P value 0.05 (two sided) was 

Clinical Findings in Heart Failure/Thomas et al 

438 April 15, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 112 

considered significant. This study was approved by the 

Scientific Committee of Cook County Hospital. 

RESULTS 

A total of 282 patients were admitted with a primary diagnosis 

of congestive heart failure. Left ventricular function 

was not documented during the index admission in 

43 patients (15%), and 14 patients (5%) had primary valvular 

disease; these patients were excluded. The remaining 

225 patients comprised the study sample, of whom 

121 (54%) had decreased left ventricular systolic function. 

Of the 225 patients, 75% (n 169) were black, 10% 

(n 22) were white, 11% (n 25) were Hispanic, and 

4% (n 9) were of other races. All but 2 of these patients 

met the Framingham criteria for congestive heart failure 

(17). 

Patients with normal systolic function were older and 

more likely to be female than were those with decreased 

systolic function (Table 1). There were no significant differences 

between the groups with respect to coronary risk 

factors (including hypertension), history of coronary disease, 

or history of chronic renal failure. A history of alcohol 

use was significantly more common in patients with 

decreased systolic function. More patients with decreased 

function were taking angiotensin-converting enzyme 

(ACE) inhibitors and digoxin (both P 0.001), whereas 

use of calcium antagonists (P 0.001) and beta-blockers 

(P 0.08) tended to be higher in patients with normal 

function. Symptoms were similar in the patients with 

normal or decreased systolic function, except that angina 

was more common in patients with decreased systolic 

function. Those with normal function tended to have a 

higher body mass index (P 0.06), and significantly 

more patients with normal function had a body mass index 

30 kg/m 2 (P 0.04). 

Mean heart rate was significantly higher in patients 

with decreased systolic function, and tachycardia (heart 

rate 100 beats per minute) was more common (Table 

1). Systolic blood pressure and pulse pressure were significantly 

higher in those with normal function, who were 

also significantly more likely to have a systolic blood pressure 

160 mm Hg or a pulse pressure 60 mm Hg. Although 

there was no difference in mean diastolic blood 

pressure between the groups, patients with normal function 

were significantly more likely to have a diastolic pressure 

110 mm Hg. There were no significant differences 

in the presence of jugular venous distention, pedal 

edema, or S 4 gallop sounds. An S 3 gallop tended to be 

more common in patients with decreased function (P 

0.07), whereas rales were significantly more common in 

those with normal function (P 0.05). 

There were no significant differences in heart rhythm 

or the prevalence of abnormal Q waves. Left ventricular

Table 1. Characteristics of Patients with Normal Left Ventricular Systolic Function (Ejection Fraction 45%) or Decreased Function 

(Ejection Fraction 45%) 

Characteristic 

Normal Systolic Function 

(n 104) 

Decreased Systolic Function 

(n 121) P Value 

Age (years) 59 13 

Number (%) or Mean SD 

54 13 0.007 

Age 60 years 54 (53) 47 (40) 0.05 

Male sex 

Risk factors 

46 (44) 79 (65) 0.001 

Hypertension 81 (78) 88 (74) 0.49 

Diabetes mellitus 42 (40) 40 (34) 0.30 

Hyperlipidemia 6 (6) 7 (6) 0.97 

Smoking 40 (39) 54 (45) 0.33 

Obesity (body mass index 30 kg/m 2 ) 

Other conditions 

60 (62) 51 (48) 0.04 

History of coronary disease 23 (22) 36 (30) 0.17 

Chronic renal failure 16 (15) 11 (9) 0.16 

Alcohol use 

Medications 

21 (20) 44 (37) 0.007 

ACE inhibitors 64 (62) 100 (85) 0.001 

Diuretics 96 (93) 112 (95) 0.59 

Beta-blockers 19 (18) 12 (10) 0.08 

Digoxin 28 (27) 67 (57) 0.001 

Calcium antagonists 34 (34) 17 (14) 0.001 

Hydralazine 

Symptoms 

16 (16) 13 (11) 0.32 

Dyspnea at rest 39 (39) 53 (44) 0.44 

Dyspnea on exertion 101 (98) 118 (98) 0.88 

Orthopnea 89 (86) 101 (86) 0.86 

Paroxysmal nocturnal dyspnea 74 (74) 89 (77) 0.57 

Angina 4 (4) 13 (11) 0.05 

Nonanginal chest pain 

Physical examination 

38 (37) 32 (26) 0.10 

Heart rate (beats per minute) 91 21 100 19 0.001 

Heart rate 100 beats per minute 32 (32) 61 (51) 0.004 

Systolic blood pressure (mm Hg) 161 40 146 31 0.002 

Systolic blood pressure 160 mm Hg 52 (50) 32 (27) 0.001 

Diastolic blood pressure (mm Hg) 92 26 89 19 0.34 

Diastolic blood pressure 110 mm Hg 26 (25) 15 (13) 0.02 

Pulse pressure (mm Hg) 69 26 57 23 0.001 

Pulse pressure 60 mm Hg 63 (61) 53 (45) 0.01 

Jugular venous distention 73 (72) 87 (74) 0.81 

Pedal edema 85 (83) 91 (75) 0.18 

Rales 83 (80) 108 (89) 0.05 

S3 gallop 25 (28) 42 (41) 0.07 

S4 gallop 

Electrocardiogram 

Rhythm 

9 (11) 7 (7) 0.39 

Sinus rhythm 78 (79) 102 (86) 0.14 

Atrial fibrillation 19 (19) 12 (10) 0.09 

Other rhythm 2 (2) 5 (4) 0.85 

Abnormal Q waves 18 (18) 25 (21) 0.56 

Left ventricular hypertrophy 22 (22) 49 (42) 0.002 

Left atrial abnormality 

Chest radiograph 

19 (22) 58 (52) 0.001 

Cardiomegaly 88 (86) 109 (93) 0.09 

Cephalization 81 (79) 106 (91) 0.02 

Pulmonary edema 14 (14) 17 (15) 0.99 

Pleural effusion 27 (26) 22 (19) 0.18 

ACE angiotensin-converting enzyme. 


April 15, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 112 439

Table 2. Sensitivity, Specificity, and Positive and Negative Predictive Values of Clinical Findings for Normal Systolic Function 

(Ejection Fraction 45%) 

hypertrophy and left atrial abnormality were significantly 

more common in those with decreased systolic function. 

Radiographic cardiomegaly and flow cephalization were 

significantly more common in patients with decreased 

function, whereas rates of pleural effusion and pulmonary 

edema were similar. 

Some clinical parameters had a high sensitivity or a 

high specificity for normal systolic function, but none 

had both a high sensitivity and a high specificity (Table 2). 

No clinical parameters had a high positive or negative 


Sensitivity Specificity 

Positive 

Predictive Value 

Negative 

Predictive Value 

Percentage 

Historical factors 

Age 60 years 52 61 53 60 

Female sex 56 65 58 63 

Hypertension 78 26 48 57 

Diabetes mellitus 40 66 51 56 

Hyperlipidemia 6 94 46 53 

Smoking 39 55 43 51 

History of coronary disease 22 70 39 51 

Chronic renal failure 15 91 59 55 

Alcohol use 

Symptoms 

20 63 32 48 

Dyspnea at rest 39 56 42 52 

Dyspnea on exertion 98 2 46 50 

Orthopnea 86 14 47 55 

Paroxysmal nocturnal dyspnea 74 23 45 50 

Angina 4 89 24 52 



37 74 54 57 

Body mass index 30 kg/m 2 

62 52 54 60 

Heart rate 100 beats per minute 31 50 34 45 

Systolic blood pressure 160 mm Hg 50 73 62 63 

Diastolic blood pressure 110 mm Hg 25 87 63 57 

Pulse pressure 60 mm Hg 61 55 54 62 

Jugular venous distention 72 26 46 53 

Pedal edema 83 25 48 63 

Rales 80 11 43 38 

S3 gallop 28 59 37 49 

S4 gallop 


11 93 56 55 

Atrial fibrillation 19 90 61 57 

Abnormal Q waves 18 79 42 53 

Left ventricular hypertrophy 22 58 31 47 



22 48 25 45 

Cardiomegaly 86 7 45 36 

Cephalization 79 9 43 34 

Pleural effusion 26 81 55 56 

Pulmonary edema 14 85 45 53 


predictive value for differentiating normal from decreased 

systolic function. 

In a multivariate analysis, several clinical findings were 

independent predictors of normal systolic function, including 

female sex (odds ratio [OR] 2.3; 95% confidence 

interval [CI]: 1.3 to 4.2; P 0.03), heart rate 100 

beats per minute (OR 1.9; 95% CI: 1.1 to 3.9; P 

0.005), use of ACE inhibitors (OR 0.34; 95% CI: 0.17 to 

0.67; P 0.001), and use of digoxin (OR 0.35; 95% CI: 

0.20 to 0.66; P 0.03). The area under the receiver oper-

ating characteristic curves for the clinical features were 

0.62 for sex and 0.63 for heart rate. Of the patients with 

decreased systolic function, 44 (36%) were male and had 

tachycardia, compared with 11 (11%) of those with normal 

function, yielding a sensitivity of 36%, specificity of 

89%, positive predictive value of 80%, and negative predictive 

value of 55% for the combination of these two 

clinical predictors. 

When medications were excluded from the multivariate 

analysis, variables that were significantly more common 

in patients with normal systolic function included 

female sex (OR 2.4; 95% CI: 1.2 to 4.6; P 0.002), 

heart rate 100 beats per minute (OR 3.5; 95% CI: 

1.7 to 7.1; P 0.001), and systolic blood pressure 

160 mm Hg (OR 3.7; 95% CI: 1.8 to 7.4; P 0.03), 

while left atrial abnormality on ECG was significantly less 

common in these patients (OR 0.24; 95% CI: 0.12 to 

0.50; P 0.04). 

There were greater differences between the 89 patients 

with markedly decreased systolic function (ejection fraction 

30%) and the 136 patients with ejection fractions 

30% (Table 3). However, the sensitivity, specificity, and 

positive and negative predictive values for these clinical 

features were again low (Table 4). 

DISCUSSION 

This prospective study of patients hospitalized with heart 

failure observed that some clinical findings were more 

common in patients with systolic or diastolic heart failure. 

However, none of these findings could differentiate 

reliably between patients with normal and decreased systolic 

function. 

Several previous studies have compared clinical findings 

in patients with systolic or diastolic heart failure, 

with inconsistent results. Some investigators have found 

that no clinical variables correlated with left ventricular 

systolic function (10,13,14,16,17), while others found— 

as we did—that older age (8,11,12), hypertension 

(7,9,15), female sex (8,9), absence of an S 3 gallop (11,12), 

and obesity (9) were associated with normal systolic function. 

Other studies have reported that normal systolic 

function was associated with atrial fibrillation (8), absence 

of jugular venous distention (9), peripheral edema 

(15), or the presence (15) or absence (12) of paroxysmal 

nocturnal dyspnea. 

One reason for the inconsistency between studies may 

be differences in study design. Most studies have been 

retrospective, and some were reviews of patients who underwent 

echocardiography or other tests to evaluate left 

ventricular function. In contrast, we performed prospective 

measurements in consecutive patients who had presented 

with heart failure. In addition, different definitions 

of “normal” systolic function have been used. We 


defined normal function as an ejection fraction 45%, as 

suggested by the European Study Group on Diastolic 

Heart Failure (20). Other studies have also used this definition 

(3,6,7,14,21,22), whereas some have used an ejection 

fraction 50% (2,4,8,11,13,23–27), 55% (12,28), 

or other values (9,10,29). When an ejection fraction cutoff 

value of 30% was used, significant differences in clinical 

features were more evident in our study, but the sensitivity, 

specificity, and predictive values of these clinical 

findings for identifying patients with severe left ventricular 

systolic dysfunction remained poor. 

Given the inconsistent and even contradictory findings 

of previous studies, it is not surprising that we did not 

find any clinical parameters that could distinguish patients 

who had normal function from those with decreased 

systolic function. Increased filling pressures are 

characteristic of both diastolic and systolic heart failure; 

all patients in our study were hospitalized, perhaps explaining 

why the clinical findings of congestion were similar 

in the two groups. Other studies have compared 

physical findings and invasive hemodynamic measurements 

in patients with chronic heart failure, and have 

shown that the physical examination is a relatively insensitive 

technique for identifying elevated filling pressures 

(30). 

There were several differences in medication use between 

the patients with normal and decreased systolic 

function. It is possible that medications may have affected 

the clinical findings; for example, the higher prevalence of 

ACE inhibitor use may have reduced the blood pressure 

and the frequency of an S 3 gallop in patients with decreased 

systolic function. Similarly, lower heart rates in 

the patients with normal function may have been due in 

part to use of beta-blockers or rate-lowering calcium antagonists. 

One puzzling issue is why the prevalence of an S 3 gallop 

did not differ significantly between the groups; the borderline 

P values (univariate P 0.07, multivariate P 

0.09) suggest that this may have been due to an insufficient 

sample size. However, an S 3 gallop was present in 

41% of patients with decreased systolic function and in 

28% of those with normal function, suggesting that it 

would not be a clinically useful discriminator even if the 

difference was statistically significant. The mechanism of 

an S 3 gallop in patients with normal function, and the 

reason for the relatively low prevalence of an S 3 gallop in 

those with decreased function, are not clear. Prior studies 

have also noted that an S 3 gallop is common in patients 

with diastolic heart failure (7,11,24). 

We found an independent association between left 

atrial abnormality on ECG and systolic dysfunction. Left 

atrial abnormality correlates more with left atrial volume 

than with left atrial pressure (19), and heart failure patients 

with low ejection fractions commonly have an enlarged 

left atrium. Left ventricular hypertrophy on ECG 


Table 3. Characteristics of Patients with a Left Ventricular Ejection Fraction 30% Compared with 30% 

Characteristic 

Ejection Fraction 

30% 

(n 136) 

Ejection Fraction 

30% 

(n 89) P Value 

Number (%) or Mean SD 

Age (years) 58 14 53 13 0.008 

Age 60 years 67 (50) 34 (39) 0.10 

Male sex 

Risk factors 

65 (49) 60 (67) 0.004 

Hypertension 108 (81) 61 (69) 0.04 

Diabetes mellitus 55 (41) 27 (30) 0.10 

Hyperlipidemia 8 (6) 5 (6) 0.91 

Smoking 54 (41) 40 (45) 0.52 

Obesity (body mass index 30 kg/m 2 ) 

Other conditions 

75 (61) 36 (44) 0.01 

History of coronary disease 32 (24) 27 (30) 0.29 

Chronic renal failure 20 (15) 7 (8) 0.11 

Alcohol use 

Medications 

29 (22) 36 (40) 0.003 

ACE inhibitors 88 (67) 76 (85) 0.002 

Diuretics 124 (94) 84 (94) 0.89 

Beta-blockers 25 (19) 6 (7) 0.01 

Digoxin 39 (30) 56 (63) 0.001 

Calcium antagonists 41 (32) 10 (11) 0.001 

Hydralazine 

Symptoms 

21 (16) 8 (9) 0.14 

Dyspnea at rest 52 (39) 40 (45) 0.39 

Dyspnea on exertion 132 (98) 87 (99) 0.55 

Orthopnea 114 (85) 76 (87) 0.64 

Paroxysmal nocturnal dyspnea 98 (75) 65 (76) 0.86 

Angina 11 (8) 6 (7) 0.71 



49 (36) 21 (24) 0.05 

Heart rate (beats per minute) 92 20 102 20 0.001 

Heart rate 100 beats per minute 46 (35) 47 (53) 0.005 

Systolic blood pressure (mm Hg) 162 39 139 27 0.001 

Systolic blood pressure 160 mm Hg 67 (50) 17 (19) 0.001 

Diastolic blood pressure (mm Hg) 92 26 88 16 0.15 

Diastolic blood pressure 110 mm Hg 32 (24) 9 (10) 0.01 

Pulse pressure (mm Hg) 70 26 51 19 0.001 

Pulse pressure 60 mm Hg 89 (66) 27 (31) 0.001 

Jugular venous distention 91 (69) 69 (79) 0.09 

Pedal edema 113 (84) 63 (71) 0.02 

Rales 111 (82) 80 (90) 0.09 

S3 gallop 33 (29) 34 (45) 0.02 

S4 gallop 


Rhythm 

14 (12) 2 (3) 0.02 

Sinus rhythm 108 (82) 72 (83) 0.91 

Atrial fibrillation 21 (16) 10 (11) 0.46 

Other rhythm 2 (2) 5 (6) 0.18 

Abnormal Q waves 26 (20) 17 (20) 0.98 

Left ventricular hypertrophy 36 (27) 35 (41) 0.04 



34 (30) 43 (52) 0.001 

Cardiomegaly 114 (86) 83 (97) 0.01 

Cephalization 107 (80) 80 (93) 0.01 

Pulmonary edema 17 (13) 14 (16) 0.47 

Pleural effusion 34 (26) 15 (17) 0.16 

ACE angiotensin-converting enzyme. 


442 April 15, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 112

Table 4. Sensitivity, Specificity, and Positive and Negative Predictive Values of Clinical Findings for Markedly Decreased Systolic 

Function (Ejection Fraction 30%) 

Sensitivity Specificity 

was more common in patients with decreased systolic 

function, even though it is commonly considered to be a 

characteristic of diastolic heart failure. This result is a 

reminder that concentric or eccentric hypertrophy is 

common in heart failure regardless of the etiology. 

A limitation of this study is that some of the history and 

physical examinations were performed by an internist 

rather than by a cardiologist, and the clinical skills of the 

examining physicians were not assessed. Our results 

might have been different if all patients had been interviewed 

and examined by a cardiologist. However, this 

study does represent the real-world situation, in which 


Positive Predictive 

Value 

Negative Predictive 

Value 

Percentage 

Historical factors 

Age 60 years 39 50 34 55 

Male sex 67 52 48 71 

Hypertension 69 19 36 48 

Diabetes mellitus 30 59 33 56 

Hyperlipidemia 6 94 38 60 

Smoking 45 59 43 62 

History of coronary disease 30 76 46 62 

Chronic renal failure 8 85 26 58 

Alcohol use 

Symptoms 

40 78 55 66 

Dyspnea at rest 45 61 43 62 

Dyspnea on exertion 99 2 40 75 

Orthopnea 87 15 40 65 

Paroxysmal nocturnal dyspnea 76 25 40 62 

Angina 7 92 35 60 



24 64 30 56 

Body mass index 30 kg/m 2 

44 39 32 51 

Heart rate 100 beats per minute 53 65 51 68 

Systolic blood pressure 160 mm Hg 19 50 20 49 

Diastolic blood pressure 110 mm Hg 10 76 22 56 

Pulse pressure 60 mm Hg 31 34 23 42 

Jugular venous distention 79 31 43 69 

Pedal edema 71 16 36 46 

Rales 90 18 42 74 

S3 gallop 45 71 51 66 

S4 gallop 


3 88 12 58 

Atrial fibrillation 11 84 32 59 

Abnormal Q waves 20 80 40 61 

Left ventricular hypertrophy 41 73 49 65 



52 70 56 67 

Cardiomegaly 97 14 42 86 

Cephalization 93 20 43 81 

Pleural effusion 17 74 31 58 

Pulmonary edema 16 87 45 62 

many patients with heart failure are managed by primary 

care physicians. A related limitation is that the study included 

all patients with an admitting diagnosis of heart 

failure; no other definition of heart failure was applied. 

However, all but 2 of the 225 patients met the Framingham 

criteria for congestive heart failure (17). 

Another limitation is that we included only patients 

admitted to the hospital. Outpatients have fewer symptoms 

and physical findings of heart failure, and it is possible 

that differences between patients with normal and 

decreased systolic function might be more apparent. Furthermore, 

only the findings at the time of admission were 


ecorded, and it is possible that the temporal evolution of 

symptoms may differ in the two groups of patients. We 

also excluded patients in whom left ventricular function 

was not measured, which may have introduced bias. 

However, only 15% of admitted patients were excluded 

for this reason. In addition, ejection fraction was determined 

by visual estimation of ECGs. Interobserver and 

intraobserver variability of estimates of ejection fractions 

were not calculated, but this method correlates well with 

radionuclide angiography (r 0.88), with low interobserver 

variability (r 0.88) in patients with adequate images 

(31). Although the data were collected prospectively, 

some physicians may have known the ejection fractions 

of their patients when they recorded their admission 

notes. In addition, this study was performed in an innercity 

hospital that had patients with a high prevalence of 

hypertension, and these results may not apply to other 

groups of patients. Nevertheless, the prevalence of diastolic 

dysfunction was similar to that reported in other 

studies (11,32). 

The etiology and prognosis of heart failure may be different 

in patients with normal or decreased systolic function 

(1,5). The treatment of diastolic dysfunction is not 

well defined; if future trials find that standard therapies 

for systolic dysfunction are equally effective in patients 

with diastolic dysfunction, recommendations to determine 

left ventricular function in patients with heart failure 

may need to be reassessed. However, our results indicate 

that differences in clinical parameters are not of sufficient 

magnitude to allow systolic function to be 

predicted reliably in a patient with heart failure, and support 

the recommendations of the American College of 

Cardiology/American Heart Association (5) and the 

Agency for Health Care Policy and Research (33) that all 

patients with heart failure should undergo echocardiography 

or radionuclide ventriculography to measure left 

ventricular function. 

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Utility of History, Physical Examination, Electrocardiogram, and ...

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