1. History and Physical Examination
Mark Drazner, MD, MSc
University of Texas Southwestern
Medical Center
3.14.15
What is the Best Way to Measure Congestion
in the Patient with Heart Failure?
ACC.15: Joint Symposium of the HFSA and ACC
No relevant disclosures
2.
3. Why Support the
Clinical Examination?
• Cheap (repeatable)
• Low risk of patient harm
• “Laying on the hands”
– Enhances patient-physician relationship
4. Why Support the
Clinical Examination?
• Cheap (repeatable)
• Low risk of patient harm
• “Laying on the hands”
– Enhances patient-physician relationship
• Provides useful information
– Assess hemodynamic status
– Risk stratify
– As with all diagnostic tests, be aware of
strengths and limitations
12. Outline
History and Physical Examination
• Identify hemodynamic congestion
– Key parameters (JVP)
– Dynamic maneuvers
• Prognostic utility of clinical congestion
13. Outline
History and Physical Examination
• Identify hemodynamic congestion
– Key parameters (JVP)
– Dynamic maneuvers
• Prognostic utility of clinical congestion
14. “The jugular venous pressure (JVP)
is the single most important marker
of the status of intravascular volume”
Jay Cohn, CHF, 2001
15. Utility of JVP and Orthopnea When
Estimating Volume Status in CHF
Only JVP 12 and orthopnea 2 pillows from the H&P
were associated with measured PCWP>30 mm Hg
Variable P value
JVP 12 4.6 (2, 10) <0.001
Orthopnea 3.6 (1, 13) <0.05
Odds ratio for
PCWP>30
Drazner et al, Circ HF, 2008
16. Can We Estimate Right Atrial
Pressure by Physical Examination?
17. Can We Estimate Right Atrial
Pressure by Physical Examination?
Yes x 3!
19. Agreement of Ultrasound and
Clinical Assessments of JVP
Clinical highClinical low
U/S
Higher
JVP
U/S
Lower
JVP
Pellicori, Int J
Cardiol, 2014
N = 211
20. Role of Clinician Experience
in Assessing JVP
AUC for RAP > 10
Fellows 0.73
Attendings 0.93
• Mayo Clinic
• N = 116
• Clinical exam 1 hour before catheterization
by 3 faculty and 6 fellows
A. From, Borlaug, et al AJM, 2011
21. Why are we interested in JVP, which
reflects RAP, to estimate left-sided
filling pressures?
22. Measured Right Atrial and Pulmonary Capillary
Wedge Pressures are Often, But Not Always,
Concordant in Advanced Heart Failure
Drazner, J Ht Lung Tx, 1999
PCW (mm Hg)
< 22 ≥ 22
RA
(mm Hg)
62 474*≥ 10
< 10
*Concordant groups
Number of patients depicted in each cell
312* 152
23. Measured Right Atrial and Pulmonary Capillary
Wedge Pressures are Often, But Not Always,
Concordant in Advanced Heart Failure
Drazner, J Ht Lung Tx, 1999
PCW (mm Hg)
< 22 ≥ 22
RA
(mm Hg)
62 474*≥ 10
< 10
*Concordant groups
Number of patients depicted in each cell
312* 152
Discordant
28%1
27%2
1 Campbell, 2011
2. Drazner, 2012
25. Drazner et al, Circ HF, 2013
Concordant
e.g., RA 11/PCWP 22
26. Drazner et al, Circ HF, 2013
RAP/PCWP<1/3
“Preserved RV”
Concordant
e.g., RA 11/PCWP 22
e.g., RA 5/PCWP 30
27. Drazner et al, Circ HF, 2013
RAP/PCWP<1/3
“Preserved RV”
RAP/PCWP>2/3
“Right-Left Equalizer”
Concordant
e.g., RA 11/PCWP 22
e.g., RA 18/PCWP 20e.g., RA 5/PCWP 30
28. Right vs. Left Sided Hemodynamic Congestion:
Sub-phenotyping HF by RAP/PCWP ratio
• Preserved RV pattern
– Low RAP/PCWP ratio: low RAP with high PCWP
– Erroneously believe patient is compensated
• Right-Left equalizer
– High RAP/PCWP ratio: RAP is higher than
expected for given PCWP
– Over-diuresis
– ? hypotension, renal failure, worse outcome
29. RAP/PCWP Ratio and Survival
Grodin et al, AHJ, in pressN=366; Cleveland Clinic
30. Outline
History and Physical Examination
• Identify hemodynamic congestion
– Key parameters (JVP)
– Dynamic maneuvers
• Hepatojugular reflux (HJR)
• Blood pressure response to Valsalva
• Bendopnea
• Prognostic utility of clinical congestion
31. Bendopnea
• Patients report SOB
when bending to put
on their shoes
• New symptom of heart
failure?
• What is the etiology of
“bendopnea”?
Bendopnea: Dyspnea when bending forward with symptom
onset within 30 seconds of bending
35. Characteristics of Bendopnea
• Occurred in 29/102 (28%) of subjects
• Median (25th, 75th percentile) time to
onset: 8 (7, 11) seconds
• 100% agreement when tested before
and during catheterization
Thibodeau, JACC HF, 2014
36. Bendopnea is Associated with
Elevated LV Filling Pressures
Thibodeau, JACC HF, 2014
Pulmonary capillary wedge pressure
Sitting Bending
0
10
20
30
40
50
Position of subject
Pulmonarycapillarywedgepressure,mmHg
Bendopnea
No Bendopnea
37. Bendopnea is Associated with
Elevated LV Filling Pressures
Thibodeau, JACC HF, 2014
Pulmonary capillary wedge pressure
Sitting Bending
0
10
20
30
40
50
Position of subject
Pulmonarycapillarywedgepressure,mmHg
Bendopnea
No Bendopnea Dyspnea
threshold
38. Bendopnea is Associated with
Elevated LV Filling Pressures
Thibodeau, JACC HF, 2014
Pulmonary capillary wedge pressure
Sitting Bending
0
10
20
30
40
50
Position of subject
Pulmonarycapillarywedgepressure,mmHg
Bendopnea
No Bendopnea Dyspnea
threshold
Will Bendopnea Improve Clinical
Assessment of Hemodynamics?
39. Outline
History and Physical Examination
• Identify hemodynamic congestion
– Key parameters (JVP)
– Dynamic maneuvers
• Prognostic utility of clinical congestion
40. No JVP
JVP
Free of
Death or
HF Hosp.
Days
Drazner et al, NEJM, 2001
P < 0.001
Elevated JVP is Associated with
Death or HF Hospitalization: SOLVD
42. Congestion and Outcome: EVEREST
Congestion Score*
0 1 2 3-9
HF hospitalization 26% 35% 35% 35%
Death 19% 25% 25% 43%
HF hosp. or Death 36% 46% 46% 60%
Ambrosy, Pang,.Gheorghiade, EHJ, 2013
*Discharge/Day 7 Congestion score: Based on extent
of orthopnea, JVD, edema (each on scale 0-3)
N=2016, placebo arm only
Median f/u: 9.9 months
43. Congestion and Outcome: EVEREST
Congestion Score*
0 1 2 3-9
HF hospitalization 26% 35% 35% 35%
Death 19% 25% 25% 43%
HF hosp. or Death 36% 46% 46% 60%
Ambrosy, Pang,.Gheorghiade, EHJ, 2013
*Discharge/Day 7 Congestion score: Based on extent
of orthopnea, JVD, edema (each on scale 0-3)
N=2016, placebo arm only
Median f/u: 9.9 months
44. Congestion and Outcome: EVEREST
Congestion Score*
0 1 2 3-9
HF hospitalization 26% 35% 35% 35%
Death 19% 25% 25% 43%
HF hosp. or Death 36% 46% 46% 60%
Ambrosy, Pang,.Gheorghiade, EHJ, 2013
*Discharge/Day 7 Congestion score: Based on extent
of orthopnea, JVD, edema (each on scale 0-3)
N=2016, placebo arm only
Median f/u: 9.9 months
45. Why do Patients Discharged Without Clinical
Congestion Have High Event Rates?
• Prior clinical congestion is deleterious
– Neurohormonal activation
– Subendocardial ischemia
46. Clinical Congestion on Admission Associated
with Cardiac Injury at Discharge
Edema Rales
OR for discharge troponin T > 0.1 ng/mL
Univariate 3.8 (1.7 – 8.2) 4 (1.9 – 8.5)
Adjusted for age
and sex
3.0 (1.3 – 6.8) 2.5 (1.1 – 5.8)
Adjusted for age,
sex, BNP,
admission SBP
3.1 (1.3 – 7.5) 2.6 (1.1 – 6.1)
Negi, PLOS ONE, 2014N = 133
47. Why do Patients Discharged Without Clinical
Congestion Have High Event Rates?
• Prior clinical congestion is deleterious
• Clinical assessment of congestion is not
performed well
– Lack of skill in estimating JVP
– Assessment at rest
• Hemodynamic congestion sometimes can
not be identified by clinical exam
– ? role for other modalities
• Post-discharge factors lead to recurrent
hemodynamic/clinical congestion, which
then leads to high event rates
48. Ability to Maintain Decongestion Post-Discharge
Is Associated with Lower Subsequent Mortality
• 146 NYHA IV patients evaluated 4 to 6
weeks after hospitalization
• Congestion score: orthopnea, JVD, edema,
weight gain, increased diuretics
• 2-year mortality
– No congestion (n=80): 13%
– 1 to 2 points (n=40): 33%
– 3 to 5 points (n=26): 59%
Lucas, AHJ, 2000
49. Conclusions
• Clinical examination allows estimation of
hemodynamics
– Orthopnea and JVP
– Right vs. Left sided hemodynamic congestion
– Dynamic maneuvers including bendopnea
• Clinical congestion associated with worse
outcomes
• Further refinement of clinical skills in
estimating hemodynamics will make it harder
for other modalities to supplant the H+P
