The Two-Minute Assessment of a patient's hemodynamic profile can be used to quickly separate a patient being evaluated for heart failure into meaningful categories. These categories can help guide the optimum therapy for the patient.



(1) Is congestion (elevated filling pressure) present at rest? (wet vs dry)

(2) Is there evidence of low perfusion? (warm vs cold)


Findings indicative of congestion and elevated filling pressure:

(1) orthopnea (shortness of breath except in an upright position)

(2) elevated jugular venous pressure

(3) increasing S3

(4) loud P2 (pulmonic component of the second heart sound)

(5) edema

(6) ascites

(7) rales (uncommon)

(8) abdominojugular reflux

(9) square wave during Valsalva


Findings indicative of poor perfusion:

(1) narrow pulse pressure

(2) pulsus alternans

(3) cool forearms and legs (distal extremities)

(4) sleepy and/or obtunded

(5) ACE-inhibitor-associated symptomatic hypotension

(6) declining serum sodium level (fluid retention)

(7) worsening renal function

Congestion at Rest



yes (wet)

low (cold)

cold and wet (C)

yes (wet)

not low (warm)

warm and wet (B)

no (dry)

low (cold)

cold and dry (L)

no (dry)

not low (warm)

warm and dry (A)



• Patients in the warm and dry group (A) with symptoms at rest or after minimal exertion may have a condition other than heart failure as the cause for the symptoms. Therapy is targeted to prevent disease progression.

• Management for each type is given on pages 631-632. If wet, the goal is to diurese; if cold, the goal is to increase perfusion.


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