Clinical Features

• Congestion (most common)

  • Clinical features of left heart failure

    • Acute dyspnea and orthopnea (i.e., worse when supine)

    • Signs of increased work of breathing (WOB)

    • Cough (occasionally with frothy, blood-tinged sputum)

    • Coarse crackles/rales (and occasionally wheezing) on lung auscultation

    • S3 gallop on heart auscultation

    • Severe cases: central cyanosis

  • Clinical features of right heart failure

    • Jugular venous distention

    • Hepatojugular reflux

    • Peripheral edema

    • Ascites

  • Flash pulmonary edema: Typically manifests with hypertension, pulmonary congestion, and minimal peripheral edema

• Hypoperfusion

  • Weakness, fatigue, altered mental status

  • Signs of poor peripheral perfusion (e.g., cold, clammy skin, peripheral cyanosis, skin mottling)

  • See also “Cardiogenic shock.”

• Blood pressure: may be low, normal, or elevated and should be interpreted in relation to the patient's baseline blood pressure

The combined presence of jugular venous distention, S3 gallop, and lung crackles/rales makes a diagnosis of acute heart failure highly likely.

Assess for clinical features that are suggestive of hypoperfusion (e.g., narrow pulse pressure, cool extremities, peripheral cyanosis, altered mental status, below baseline blood pressure) to identify patients with or at risk of cardiogenic shock