Physical Examination in Patients With Suspected Heart Failure
Physical Examination in Patients With Suspected Heart Failure
Aims The prognostic value of signs of congestion in patients suspected of having chronic heart failure (CHF) is unknown. Our objectives were to define their prevalence and specificity in diagnosing CHF and to determine their prognostic value in patients in a community heart failure clinic.
Methods and results Analysis of referrals to a community clinic for patients with CHF symptoms. Systolic CHF (S-HF) was defined as left ventricular ejection fraction (LVEF) ≤45%, heart failure with normal ejection fraction (HeFNEF) as LVEF > 45%, and amino-terminal pro-brain natriuretic peptide >50 pmol L; other subjects were defined as not having CHF. Signs of congestion were as follows: no signs; right heart congestion (RHC: oedema, jugular venous distension); left heart congestion (LHC: lung crackles); or both (R + LHC). Of 1881 patients referred, 707 did not have CHF, 853 had S-HF, and 321 had HeFNEF. The median inter-quartile range (IQR) age was 72 years (64–78), 40% were women, and LVEF was 47% (35–59). Overall, 417 patients had RHC of whom 49% had S-HF and 21% HeFNEF. Eighty-five patients had LHC of whom 43% had S-HF and 20% had HeFNEF. One hundred and seventy-two patients had R + LHC of whom 71% had S-HF and 16% had HeFNEF. During a median (IQR) follow-up of 64(44–76) months, 40% of the entire patient cohort died. The combination of R + LHC signs was an independent marker of an adverse prognosis (χ-log-rank test = 186.1, P< 0.0001).
Conclusion Clinical signs of congestion are independent predictors of prognosis in ambulatory patients with suspected CHF.
Signs of congestion are commonly found in patients with chronic heart failure (CHF). Right heart congestion (RHC) on clinical examination is defined by ankle oedema, raised jugular venous pressure, ascites, and/or hepatomegaly. Left heart congestion (LHC) is defined by the presence of pulmonary crackles or wheeze. Other signs of heart failure, including cardiac enlargement (increased area of cardiac dullness and displaced apex beat) or cardiac strain (third heart sound), are more difficult to identify, particularly for non-cardiologists, but do predict the presence of CHF. The prevalence of a third heart sound decreases with the introduction of beta-blockers. The use of the clinical examination is declining as clinical signs are non-specific for the diagnosis of CHF and can be seen in other conditions, such as lung disease, and insensitive, as many patients with heart failure have no apparent clinical signs. Furthermore, clinical signs have limited reliability in estimating haemodynamics in patients with CHF. Physical examination of the patients is often not recorded in real life or in clinical studies. Furthermore, the individual clinical signs have always been studied alone and never in combination. Technologies, such as echocardiography, and specific blood markers, such as brain natriuretic peptide (BNP), are progressively replacing the clinical examination. However, the new tools also have their own weaknesses and complexity.
A sub-study of the SOLVD trial showed that some clinical signs of CHF, such as elevated jugular pressure or third heart sound, have prognostic value, but their value in a wider population of ambulatory patients with CHF is unknown.
We sought to investigate the relation between clinical signs of congestion and prognosis in patients suspected of having CHF, and to compare their prognostic valve with other clinical, biological, and echocardiographic variables. Our objective was to define: first, the prevalence of clinical signs of congestion in ambulatory patients suspected of having CHF; second, to describe the clinical characteristics associated with those signs; third, to analyse the specificity of the signs in diagnosing CHF; and fourth, to determine their prognostic value.
Abstract and Introduction
Abstract
Aims The prognostic value of signs of congestion in patients suspected of having chronic heart failure (CHF) is unknown. Our objectives were to define their prevalence and specificity in diagnosing CHF and to determine their prognostic value in patients in a community heart failure clinic.
Methods and results Analysis of referrals to a community clinic for patients with CHF symptoms. Systolic CHF (S-HF) was defined as left ventricular ejection fraction (LVEF) ≤45%, heart failure with normal ejection fraction (HeFNEF) as LVEF > 45%, and amino-terminal pro-brain natriuretic peptide >50 pmol L; other subjects were defined as not having CHF. Signs of congestion were as follows: no signs; right heart congestion (RHC: oedema, jugular venous distension); left heart congestion (LHC: lung crackles); or both (R + LHC). Of 1881 patients referred, 707 did not have CHF, 853 had S-HF, and 321 had HeFNEF. The median inter-quartile range (IQR) age was 72 years (64–78), 40% were women, and LVEF was 47% (35–59). Overall, 417 patients had RHC of whom 49% had S-HF and 21% HeFNEF. Eighty-five patients had LHC of whom 43% had S-HF and 20% had HeFNEF. One hundred and seventy-two patients had R + LHC of whom 71% had S-HF and 16% had HeFNEF. During a median (IQR) follow-up of 64(44–76) months, 40% of the entire patient cohort died. The combination of R + LHC signs was an independent marker of an adverse prognosis (χ-log-rank test = 186.1, P< 0.0001).
Conclusion Clinical signs of congestion are independent predictors of prognosis in ambulatory patients with suspected CHF.
Introduction
Signs of congestion are commonly found in patients with chronic heart failure (CHF). Right heart congestion (RHC) on clinical examination is defined by ankle oedema, raised jugular venous pressure, ascites, and/or hepatomegaly. Left heart congestion (LHC) is defined by the presence of pulmonary crackles or wheeze. Other signs of heart failure, including cardiac enlargement (increased area of cardiac dullness and displaced apex beat) or cardiac strain (third heart sound), are more difficult to identify, particularly for non-cardiologists, but do predict the presence of CHF. The prevalence of a third heart sound decreases with the introduction of beta-blockers. The use of the clinical examination is declining as clinical signs are non-specific for the diagnosis of CHF and can be seen in other conditions, such as lung disease, and insensitive, as many patients with heart failure have no apparent clinical signs. Furthermore, clinical signs have limited reliability in estimating haemodynamics in patients with CHF. Physical examination of the patients is often not recorded in real life or in clinical studies. Furthermore, the individual clinical signs have always been studied alone and never in combination. Technologies, such as echocardiography, and specific blood markers, such as brain natriuretic peptide (BNP), are progressively replacing the clinical examination. However, the new tools also have their own weaknesses and complexity.
A sub-study of the SOLVD trial showed that some clinical signs of CHF, such as elevated jugular pressure or third heart sound, have prognostic value, but their value in a wider population of ambulatory patients with CHF is unknown.
We sought to investigate the relation between clinical signs of congestion and prognosis in patients suspected of having CHF, and to compare their prognostic valve with other clinical, biological, and echocardiographic variables. Our objective was to define: first, the prevalence of clinical signs of congestion in ambulatory patients suspected of having CHF; second, to describe the clinical characteristics associated with those signs; third, to analyse the specificity of the signs in diagnosing CHF; and fourth, to determine their prognostic value.
