Show notes
CardioNerds Amit Goal, Daniel Ambinder, & Dr. Alex Pipilas (FIT, Boston University) discuss the clinical examination in patients with heart failure with Dr. Mark Drazner, professor of medicine, clinical chief of cardiology, and medical director of the LVAD and Cardiac Transplantation Program at UT Southwestern. In this pearl laden episode, they discuss how the exam can be used to non-invasively assess a patient's hemodynamic status, risk stratify and inform prognosis, and guide management. They also discuss ways to master the evaluation of the JVP and categorize patients based on their RA:PCWP ratio.
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Pearls - Clinical Examination in Heart Failure
Begin hemodynamic assessment with the evaluation of congestion (“wet” vs “dry”) and perfusion (“cold” vs “warm”). In a 2x2 table, this breaks patients into 4 broad hemodynamic profilesThe most sensitive markers of congestion (PCWP 30) are JVP 12 with an OR of 4.6 and the presence of orthopnea with an OR of 3.6“If you are cold, you are cold, if you are warm, you can still be cold”. Sensitivity for clinical markers of low cardiac index is very poor. Consider a low output state in patients with poor response to what are thought to be appropriate therapiesMost patients with acute on chronic heart failure have an RA:PCWP ratio of 1:2. These patients are the so called “concordant” phenotype. There are two other sub-phenotypes:The “RV equalizer group” have an elevated RA:PCWP ratioThe “RV compensated” group have a lower RA:PCWP ratioClinical congestion at the time of hospital admission as well as discharge portends a poor prognosis for patients with heart failure
Show notes - Clinical Examination in Heart Failure
Figure 1
1. What is the physical exam important in patients with heart failure?
Important to view the physical exam as a diagnostic test with strengths and limitationsIt is a noninvasive way to assess hemodynamics and risk stratify patientsCan provide information on prognosisMay enhance the provider-patient relationship
2. How might we classify hemodynamics noninvasively?
Framework begins with the “Stevenson” Classification, developed by Dr. Lynne StevensonClassifies patients along two axes: congestion and perfusionCongestion is the assessment of overall volume status and estimation of right and left sided filling pressures, broadly broken up into “wet” or “dry”:“Wet”, PCWP 15mmHg“Dry”, PCWP 2.2“Cold”, Cardiac index 12 predicts PCWP 30 with an OR of 4.6 (Drazner, 2008).Rapidly developing ascites or edemaSquare wave test. The square wave test takes advantage of an abnormal response to Valsalva in patients with low systolic function and elevated filling pressures. In those with congestion, the MAP fails to fall with decrease in RV and LV preload from the Valsalva maneuver due to preexisting high filling pressures. This is likely the best evidence that the patient has elevated filling pressures and may help to identify patients with the discordant hemodynamic phenotypes.Symptoms:Orthopnea: one of the two most sensitive markers for congestion such that the presence of orthopnea predicts PCWP 30 with an OR of 3.6 (Drazner, 2008).Bendopnea: the sensation of feeling breathless within 30 seconds of bending over. Bendopnea is associated with higher filling pressures and low cardiac index (Thibodeau JT T. A.-M., 2014), with increased risk of short term heart failure admission ( (Thibodeau JT J. B., 2017), and with elevated VE/VCO2 (more advanced HF marker from CPET) (Dominguez-Rodriguez A, 2016). Relief of bendopnea during hospitalization is associated with greater fall in median NT-proBNP.The following are less helpful for identifying patients with acute on chronic HFRales have a low sensitivity and specificity for acute on chronic decompensated heart failure. If rales are present in chronic HF patients, consider looking for pulmonary pathology. This doesn’t apply for patients with acute MI or flash pulmonary edema.Weight may be misleading as heart failure is a cachexia promoting illness such that variation in weight may not be referred to fluid status alone. Volume overload often leads to appetite changes and weight loss as well as fluid retention which together can lead to net negligible weight change. Additionally once patients are euvolemic and clinically improved, they might gain true caloric weight which makes tracking “dry weights” difficult. Weight may be helpful over the short term i.e with a report of 10lbs of weight gain within the past week + significant stigmata of overload. With these considerations, we must be cautious regarding targeting a fixed “dry” weight over long periods of time given true changes in body weight.Adjunctive data may help adjudicate the bedside assessment of congestion:Prognosis is better with down trending natriuretic peptides but no data clearly suggests benefit from tailoring therapy based on these levels.Echo parameters such as the PASP, mitral inflow pattern, and IVC size may be helpful in the right context.Implantable PA sensors (i.e. CardioMems) may be helpful. A large RCT looking at this, Guide-HF, trial is still enrolling.
4. What are some tips & tricks for measuring the JVP?
We are not looking for venous structure, but rather referred pulsating waves, which are usually better seen than felt.Look on both sides of the neck!Carotid vs Jugular vein – if you compress BELOW the pulsation and it goes away then it is a VENOUS pulsation. If not, then it is likely carotid. Venous pulsation (not carotid pulsation) will change in height as you adjust the degree of patient’If unable to see the pulsation, sit the patient upright and assess. It may be too high to see when recumbentCan use the EJ if it is respirophasic. If it isn’t then the high level could be due to a valve in the vein in which case we need to be cautious with interpretation.
5. What is the connection of the JVP (i.e estimated RA pressure) to left sided filling pressures (i.e PCWP/LVEDP) (Drazner 2008)?
The RAP:PCWP ratio is ~1:2 (“concordant”) in 70-75% of patients in acute on chronic heart failure from ESCAPE trial data. Importantly, this relationship does not hold in all groups of patients including those with acute MI or other conditions which may cause discordance between right- and left-sided filling pressures like primary pulmonary hypertension, significant valvular disease, etc.This relationship does not hold ~25-30% of the time, where the RAP and PCWP are “discordant.” The two sub-phenotypes to think about are: Right/left equalizers: high RAP:PCWP ratio (ratio ~≥ 2:3). Clinically, a high JVP may overestimate the overall fluid status. They may run into hypotension and worsening renal function because left sided pressures are lower than you would estimate by the JVP. These tend to be sicker patients with a generally worse prognosis (Grodin JL, 2015).Compensated RV group: low RAP:PCWP ratio (ratio ~≤ 1:3). In contrast to the right/left equalizers, those with a “compensated RV” may have a JVP which underestimates the overall fluid status since the RAP is lower for a given PCWP. Consider this phenotype in those with classic left sided HF symptoms despite a relatively low or normal JVP.There are no clear clinical makers to identify patients who are in the discordant phenotypes but if the clinical course is not what you expect, consider exploring if a patient’s hemodynamics fall within these discordant phenotypes.If a patient has had a RHC in the past, you can use their previous RA:PCWP ratio to estimate left sided filling pressures with JVP during subsequent encountersThere is some data to suggest that a given patient us unlikely to move from one extreme to another, at least over a short period of time (i.e move from right/left equalizers to compensated RV ect)More likely, a patient may move from extremes to the middle with either progression of disease or improvement
6. What is the role of the clinical exam in the assessment of perfusion: “Warm” or “Cold”?
“If they are cold, they are cold. If they are warm, they still may be cold.” In other words, the sensitivity of the clinical evaluation is poor for the diagnosis of poor perfusion, but the specificity is high.