All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor ----------------------------------------------------------- NOTE: You can make the print bigger with the font button on your browser! (It's usually a big "A") ---------------------------------------------------------- The Physical Exam In Heart Failure Patients SUMMARY Doctors place less and less importance on physical exam in heart failure patients. We studied whether a physical exam gives important information in CHFers. We analyzed data on 2479 patients from the SOLVD trial. High pressure in the jugular vein and a third heart sound were each independently linked to later CHF hospitalizations or death. Patients with at least one of these two physical exam findings had higher risk for all- cause mortality. LONG VERSION Doctors are becoming less skilled at doing physical exams for heart patients. Doctors' interest in doing such exams is less as well. Advances in technologies like echocardiograms are one reason. As the number of doctors well-trained in the art of the cardiac physical exam declines, there may not be enough teachers to pass these skills on to younger doctors. Physical Exam to Check Heart Function A cardiac index under 2.2 L/min/m2 as measured by a right- side heart cath is often used as the dividing line between sufficient and insufficient heart function at rest. It would be better to have a non-invasive way to estimate this, since right-heart cath carries risks. A device that measures changes in electrical current across the upper body to measure stroke volume and cardiac output is now available (BioZ), and seems fairly accurate. The good old physical exam may be another way to check heart output. Low "proportional" pulse pressure (the difference between systolic and diastolic pressures divided by the systolic pressure) suggests low heart output. In 50 CHFers (1/3 ischemic and 2/3 of non-ischemic cause) with an average EF of 18%, proportional pulse pressure was linked to cardiac index. In that study, a proportional pulse pressure under 26% strongly indicated cardiac index under 2.3 L/min/m2. (91% sensitive and 83% specific) High Left Heart Filling Pressures Many acute CHF symptoms are from high filling pressures in the heart's left ventricle (LV). Physical exam can check things that suggest high filling pressures, including sounds in the lungs (rales), swelling in the legs and stomach (edema), high pressure in the jugular vein in the neck, and an abnormal response to the "Valsalva maneuver." Some of these reflect right-sided heart filling pressures, but they still help estimate LV pressures since 80% of CHFers have abnormal pressures in both right and left sides of the heart. A raised (distended) jugular vein in the neck either at rest or after applying pressure to the stomach, helps detect high LV filling pressures. In a study of 65 patients who did not all have CHF, such a result was 93% sensitive and 86% specific for detecting PCWP over 15 mmHg. In a study of 52 patients being evaluated for heart transplant, jugular vein exam was 81% sensitive and 80% specific for PCWP over 17 mmHg. Other studies of CHFers also found jugular exam better than edema or lung sounds for detecting high left-sided filling pressures. Many heart failure specialists consider examining for jugular vein pressure extremely important, if not vital, in their practices. The Valsalva Maneuver Systolic blood pressure (SBP) response to the Valsalva maneuver may show if a CHFer is retaining fluid. The normal SBP response during the 4 phases of the maneuver has 3 easily detected parts. When strain begins during the Valsalva maneuver, SBP increases from the quick increase in internal pressure. During the ongoing strain, SBP falls below its original level due to less blood return through the veins. When the strain is released, SBP abruptly falls further. In healthy people, SBP then increases above the initial level again - called "overshoot." So in healthy people : SBP increases above baseline, then decreases below baseline, then again increases above baseline during the overshoot. CHFers with high left-sided filling pressures have a different SBP response during the Valsalva maneuver. Because the fall in SBP during the strain phase is from decreased LV filling, CHFers' SBP remains increased throughout the strain phase because LV filling remains adequate. Release of the strain is not followed by an "overshoot" of blood pressure. CHFers' response here is called "square wave" - an increase in SBP that persists throughout the strain phase and then returns to baseline levels when the strain is released. SBP response to the Valsalva maneuver also related to neurohormone levels such as ANP and BNP; to exercise tolerance; and to other measures of CHF in a study of 45 patients with stable CHF and an average EF of 28%. In this study, average BNP level was 282 pg/mL in patients with an abnormal response to the Valsalva maneuver. This compared to average BNP level of 81 pg/mL in patients with a normal response. The Valsalva maneuver is easily done unless a-fib is present. The Physical Exam and Prognosis A low "congestion score" based on * absence * of high jugular vein pressure and edema, shortness of breath lying down, weight gain, and recent increase in diuretics, usually means a favorable outcome despite previous class 4 CHF. Third Heart Sound We studied data from the SOLVD ACE inhibitor trial. 2569 CHFers with EF less than 36% took either enalapril (Vasotec) or placebo. Patients were followed for 32 months. Patients with high jugular pressure or a third heart sound (S3) had more advanced heart failure. Those with high jugular pressure were more often class 3 to class 4 (63%) than those with normal jugular pressure (29%). Patients with an S3 were also more often class 3 or class 4 than patients without a third heart sound. Patients with an S3 or high jugular pressure had lower EF and faster heart rate, and were roughly 1-1/2 times more likely to have an adverse event or die. A complex analysis was done including patients' age, EF, heart class, enalapril versus placebo, sex, ischemic or non- ischemic cause of CHF, race, a-fib; blood levels of sodium and creatinine, history of diabetes, history of high blood pressure, and use of beta-blockers, digoxin, or diuretics. High jugular pressure on physical exam was linked to higher risk for hospitalization for CHF (1.32 times more likely than those without), death or hospitalization for CHF (1.3 times), and pump failure death (1.37 times). A third heart sound was linked to a higher risk for hospitalization for CHF (1.42 times more likely than those without), death or hospitalization for CHF (1.22 times), and pump failure death (1.40 times). This suggests that high jugular pressure or third heart sound on physical exam is linked to poorer outcomes, independent of other factors. Why is unknown. We think that high jugular pressure and a third heart sound are linked to high filling pressures in the heart, and high filling pressures are linked to poor prognosis. CONCLUSION The physical exam in heart patients is not taken seriously enough today due to advances in technology. Studies suggest that physical exam is a reliable tool for checking heart output and increased left-sided filling pressures in CHF patients. We believe physical exam offers independent prognostic value in CHFers as well. Two common physical exam findings suggest this : high jugular vein pressure and a third heart sound. Title: The Prognostic Value of the Physical Examination in Patients With Chronic Heart Failure. Authors: J. Eduardo Rame, M Phil, Daniel L. Dries, Mark H. Drazner. Source: CHF 9(3):170-175, 2003. Posted: 06/17/2003.