Dr. Ghali correctly points out the importance of the physical examination in patients admitted for heart failure. Although the report by Dr. Ghali and his coworkers [1] raises the intriguing possibility that physical findings may provide important clues with which to distinguish patients with heart failure and preserved systolic function from those with systolic dysfunction, several caveats are warranted. The overall number of patients in the study by Ghali and coworkers was small, and the size of the patient subset in which a combination of findings yielded a specificity of 100% is uncertain. Thus, the conclusions of that study are tentative and must be confirmed by a larger series. We also note that the high specificity using a combination of physical findings was achieved at the expense of a very low sensitivity (30%). Finally, Ghali and coworkers' study sample consisted of patients hospitalized with an exacerbation of heart failure in the setting of long-standing symptoms. It is unclear whether the combination of criteria evaluated by Ghali and colleagues will apply to other patient groups with heart failure and preserved systolic function.

As we mentioned [2], the key element in making the appropriate diagnosis is diagnostic suspicion and the recognition that a significant subset of patients admitted with heart failure will have preserved systolic function. Whether or not the physical examination suggests preserved or impaired systolic function, we do not believe that therapeutic decisions should be based on these findings alone. Rather, all patients admitted with heart failure symptoms should have noninvasive evaluation of left ventricular systolic performance, using echocardiography or radionuclide angiography, in order to more precisely define the underlying systolic function, with its attendant important therapeutic and prognostic implications.