INTRODUCTION: We aimed to identify the best tools from history and physical examination that predict severity of heart failure (HF) exacerbation among patients with an ejection fraction (EF) ≤ 30%. METHODS: Patients enrolled in the ESCAPE trial were divided into tertiles according to the combined value of pulmonary capillary wedge pressure (PCWP) and right atrial pressure (RAP) which we used as a marker of volume loading of both pulmonary and systemic compartments. Variables of congestion from history and physical examination were examined across tertiles. RESULTS: There were significant differences across tertiles (tertile 1: PCWP + RAP < 31 mm Hg, tertile 2: PCWP + RAP 31-42 mm Hg and tertile 3: PCWP + RAP > 42 mm Hg) with respect to baseline B­type natriuretic peptide (P = 0.016), blood urea nitrogen (P = 0.022), sodium (P = 0.015), left ventricular ejection fraction (P = 0.005), and inferior vena cava diameter during inspiration (P < 0.001) and expiration (P < 0.001). With respect to variables of congestion from history and physical examination, we found significant differences across tertiles predominantly in signs of right sided failure, specifically, the frequency of jugular venous distension (JVD, P < 0.001) and JVD > 12 cmH2O (p < 0.001), lower extremity edema (P = 0.001) and lower extremity edema of at least grade 2 + (P = 0.029), and positive hepatojugular reflux (HJR, P = 0.022) but no differences in patients' symptoms such as degree of dyspnea, orthopnea or fatigue. With regards to post-discharge outcomes, there was a significant difference across tertiles in all-cause mortality (P = 0.029) and rehospitalization for HF (P = 0.031) at 6 months following randomization. Receiver operator characteristic curves showed that admission PCWP + RAP had an area under the curve of 0.623 (P = 0.0075) and 0.617 (P = 0.0048), respectively, in predicting 6­month all-cause mortality and rehospitalization for HF. CONCLUSION: The presence and extent of JVD and lower extremity edema, and a positive HJR are better than other signs and symptoms in identifying severity of HF exacerbation among patients with EF ≤ 30%.