Prognostic Value of the Physical Examination in Patients With Heart Failure and Atrial Fibrillation: Insights From the AF-CHF Trial (Atrial Fibrillation and Chronic Heart Failure)

Study Questions:

What is the prognostic value of physical examination (i.e., peripheral edema, jugular venous distension, a third heart sound, and pulmonary rales)?


The study cohort was comprised of 1,376 patients, 81% male, mean age 67 ± 11 years, with symptomatic left ventricular systolic dysfunction and enrolled in the AF-CHF (Atrial Fibrillation and Congestive Heart Failure) trial. All patients had a history of nonpermanent atrial fibrillation. A post-hoc analysis was conducted using univariate and multivariate Cox regression analyses to determine the prognostic value of baseline physical examination findings.


They found that 30.9% (n = 425) had peripheral edema, 21.6% (n = 297) had jugular venous distension, 15% (n = 207) had a third heart sound, and 12.9% (n = 178) had pulmonary rales; 25.9% (n = 357) died from cardiovascular causes, with a mean follow-up of 37 ± 19 months. In univariate analyses, they found that four physical examination findings (i.e., peripheral edema, jugular venous distension, a third heart sound, and pulmonary rales) were associated with cardiovascular mortality (all p values < 0.01). However, with multivariate analyses, using all four signs as potential covariates, only peripheral edema (hazard ratio, 1.25; 95% confidence interval, 1.00-1.57; p = 0.048) and pulmonary rales (hazard ratio, 1.41; 95% confidence interval, 1.07-1.86; p = 0.013) were associated with cardiovascular mortality, independent of other variables. This multivariate analyis included standard clinical, electrocardiographic, and echocardiographic parameters: 1) peripheral edema and pulmonary rales were associated with a twofold increased risk of heart failure–related mortality; 2) pulmonary rales independently predicted hospitalizations for heart failure; and 3) jugular venous distension was associated with a 48% increased risk of heart failure–related mortality.


The authors concluded that even today, congestive signs on the clinical examination (i.e., peripheral edema, jugular venous distension, a third heart sound, and pulmonary crackles) are important prognostic markers in congestive heart failure.


This is an important study because it suggests the relevancy of physical examination despite the presence of ‘sophisticated’ imaging techniques to determine ejection fraction, cardiopulmonary stress test, and biomarkers such as B-type natriuretic peptide. The fact that the correlation of third heart sound with prognosis was not as strong as other signs may simply reflect the difficulty of eliciting this sign by the bedside. Important limitations of this study include that it was a retrospective analysis and that these results may not apply to a population with low prevalence of atrial fibrillation. Prospective studies correlating symptoms including New York Heart Association class, signs, and commonly used laboratory biomarkers should validate the important findings of this study.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Prognosis, Multivariate Analysis, Heart Failure, Edema, Ventricular Dysfunction, Left, Regression Analysis, Physical Examination, Heart Sounds, Echocardiography

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