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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
Why Support the
Clinical Examination?
• Cheap (repeatable)
• Low risk of patient harm
• “Laying on the hands”
– Enhances patient-physician relationship
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
Types of Congestion
• Hemodynamic congestion
– Elevated LV filling pressure (PCWP)
– Elevated RV filling pressure (RAP)
• Clinical congestion
– Hemodynamic congestion + signs/symptoms of HF
Modified from Gheorghiade
Types of Congestion
• Hemodynamic congestion
– Elevated LV filling pressure (PCWP)
– Elevated RV filling pressure (RAP)
• Clinical congestion
– Hemodynamic congestion + signs/symptoms of HF
Modified from Gheorghiade
What is the best modality to identify
hemodynamic congestion?
Clinical Congestion
Hemodynamic Congestion
• High RAP
• High PCWP
Adverse Events
• Progressive HF
• HF Hospitalization
• Death
Clinical Congestion
Hemodynamic Congestion
• High RAP
• High PCWP
Adverse Events
• Progressive HF
• HF Hospitalization
• Death
Clinical Congestion
Hemodynamic Congestion
• High RAP
• High PCWP
Adverse Events
• Progressive HF
• HF Hospitalization
• Death
Clinical Congestion
Hemodynamic Congestion
• High RAP
• High PCWP
Adverse Events
• Progressive HF
• HF Hospitalization
• Death
Biomarkers
• Natriuretic peptides
• Hemoconcentration
Implantable
monitors
Blood volume
Clinical Congestion
Hemodynamic Congestion
Adverse Events
• Progressive HF
• HF Hospitalization
• Death
Biomarkers Implantable monitorsBlood volume
=
Outline
History and Physical Examination
• Identify hemodynamic congestion
– Key parameters (JVP)
– Dynamic maneuvers
• Prognostic utility of clinical congestion
Outline
History and Physical Examination
• Identify hemodynamic congestion
– Key parameters (JVP)
– Dynamic maneuvers
• Prognostic utility of clinical congestion
“The jugular venous pressure (JVP)
is the single most important marker
of the status of intravascular volume”
Jay Cohn, CHF, 2001
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
Can We Estimate Right Atrial
Pressure by Physical Examination?
Can We Estimate Right Atrial
Pressure by Physical Examination?
Yes x 3!
Estimated vs. Measured RAP > 12:
ESCAPE
Drazner, Circ HF, 2008
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
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
Why are we interested in JVP, which
reflects RAP, to estimate left-sided
filling pressures?
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
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
Distribution of RAP/PCWP Ratio
in the ESCAPE Trial
Drazner et al, Circ HF, 2013
Drazner et al, Circ HF, 2013
Concordant
e.g., RA 11/PCWP 22
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
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
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
RAP/PCWP Ratio and Survival
Grodin et al, AHJ, in pressN=366; Cleveland Clinic
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
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
JACC: Heart Failure Young Author
Achievement Award
Hemodynamic Assessment With Positional Changes
Supine
Sitting
Bending
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
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
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
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?
Outline
History and Physical Examination
• Identify hemodynamic congestion
– Key parameters (JVP)
– Dynamic maneuvers
• Prognostic utility of clinical congestion
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
Clinical Congestion at Hospital
Discharge is Adverse Risk Factor
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
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
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
Why do Patients Discharged Without Clinical
Congestion Have High Event Rates?
• Prior clinical congestion is deleterious
– Neurohormonal activation
– Subendocardial ischemia
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
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
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
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
Clinical Examination Remains The Foundation
For Assessment of Congestion
Joint Symposium of the HFSA and ACC

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Joint Symposium of the HFSA and ACC

  • 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
  • 5. Types of Congestion • Hemodynamic congestion – Elevated LV filling pressure (PCWP) – Elevated RV filling pressure (RAP) • Clinical congestion – Hemodynamic congestion + signs/symptoms of HF Modified from Gheorghiade
  • 6. Types of Congestion • Hemodynamic congestion – Elevated LV filling pressure (PCWP) – Elevated RV filling pressure (RAP) • Clinical congestion – Hemodynamic congestion + signs/symptoms of HF Modified from Gheorghiade What is the best modality to identify hemodynamic congestion?
  • 7. Clinical Congestion Hemodynamic Congestion • High RAP • High PCWP Adverse Events • Progressive HF • HF Hospitalization • Death
  • 8. Clinical Congestion Hemodynamic Congestion • High RAP • High PCWP Adverse Events • Progressive HF • HF Hospitalization • Death
  • 9. Clinical Congestion Hemodynamic Congestion • High RAP • High PCWP Adverse Events • Progressive HF • HF Hospitalization • Death
  • 10. Clinical Congestion Hemodynamic Congestion • High RAP • High PCWP Adverse Events • Progressive HF • HF Hospitalization • Death Biomarkers • Natriuretic peptides • Hemoconcentration Implantable monitors Blood volume
  • 11. Clinical Congestion Hemodynamic Congestion Adverse Events • Progressive HF • HF Hospitalization • Death Biomarkers Implantable monitorsBlood volume =
  • 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!
  • 18. Estimated vs. Measured RAP > 12: ESCAPE Drazner, Circ HF, 2008
  • 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
  • 24. Distribution of RAP/PCWP Ratio in the ESCAPE Trial Drazner et al, Circ HF, 2013
  • 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
  • 32.
  • 33. JACC: Heart Failure Young Author Achievement Award
  • 34. Hemodynamic Assessment With Positional Changes Supine Sitting 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
  • 41. Clinical Congestion at Hospital Discharge is Adverse Risk Factor
  • 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
  • 50. Clinical Examination Remains The Foundation For Assessment of Congestion