Clinical evaluation of congestion

az MU

M

Congestion in Heart Failure –

Clinical Examination

H.P. Brunner-La Rocca, MD, FESC – Prof of CardiologyHead Heart Failure Clinic – Vice Chairman Dept. Cardiology

Maastricht University Medical Centre, The Netherlands

U

M

Declaration of Conflict of InterestsDeclaration of Conflict of Interests

None for this specific talkNone for this specific talk

Research grants from Roche Diagnostics, AstraZenecaResearch grants from Roche Diagnostics, AstraZenecaHonorary from Roche Diagnostics, NovartisHonorary from Roche Diagnostics, Novartis

az MU

M

Clinical examination of congestion

oAs we have moved into the era of accelerating advances in technology, the underpinning procedure of all medicine, the physical examination, is at risk of extinction. The death knell may well be the retirement of the last generation of physicians proficient in the bedside examination.

oIn this regard, the medical profession, with its educational system, is its own culprit—another example of “We have met the enemy and he is us!”

Leier et Chatterjee. CHF 2007; 13: 41

az MU

M

Clinical Examination of Congestion

oWhat do we do?o History / symptomso Clinical examination

oHow accurate are we in clinically examining congestion / heart failure?

oWhat does it tell us in addition?oConclusion

az MU

M

Clinical Examination in Heart Failure

o Disease, which may cause heart failure? Known CHF? Cardiovascular risk factors? Toxic?

o Diseases / circumstances, which make another disease probable?

o Medication?o Symptoms and signs of forward / backward failure?o Symptoms and signs of left or right heart failure?

az MU

M

Common Causes of Fluid Overload / Decompensation

oAnaemia oAtrial fibrillation or other arrhythmias oSalt intake, water intake, medication mal-compliance oFluid retention from drugs (e.g., chemotherapy, COX-

1 and 2 inhibitors, glitazones, glucocorticoids)oHyper- or hypothyroid disease oPulmonary causes (e.g. PAH, pulmonary embolism) oRenal causes (e.g. renal failure, nephrotic syndrome) oSleep apnea oSystemic infection or septic shock

King et al. Am Fam Physician. 2012; 85: 1161

az MU

M

Symptoms of Congestion

Left hearto Dyspnoea (tachypnoea)o Orthopnoeao PNDo Cougho Weight gain

Right hearto (Dyspnoea)o Peripheral oedemao Weight gaino Loss of appetiteo Abdominal swelling

az MU

M

General Clinical Examination

oHeart rate: frequency / regularity?oBlood pressure: hypertension / hypotensionoAnaemic?oCyanotic?oObese / cachectic?oScars?

az MU

M

Acute heart failure –Clinical Assessment

Forrester et al. Am J Cardiol 1977; 39: 137

DryDryColdColdHypovolHypovol. . ShockShock

Filling pressureFilling pressure

CardiacCardiacperformanceperformance

normalnormal elevatedelevated

normalnormal

reducedreduced

DryDryWarmWarmNormalNormal

WetWetColdColdCardiogenicCardiogenic Shock Shock

WetWetWarmWarmPulmPulm. Congestion. Congestion

az MU

M

How to Examine Patients (with Respect to Heart Failure)?

oCardiac impulse (left / right)oJugular vein: 45°, externa / interna. HJRoAuscultation of the heart:

o Heart sounds, 3rd / 4th ?o Murmurs? Systolic versus diastolic?

oAuscultation of the longs:o Rales / obstruction / reduced breathing?

oLiver: enlarged? Ascites?oPeripheral oedema?

az MU

M

Forward Failure

o Primarily signs of left heart failureo Reduced cardiac function

o Hypotensiono Cold periphery, cyanosiso Sings of reduced perfusion of different organs

(combined forward and backward failure)o Kidneys, liver (lab findings)o Brain

o Cachexia

az MU

M

Method of examinationJugular vein

az MU

M

Differentiation of Venous Pulse from Carotid Pulse

Venous PulseVenous Pulse Carotid PulseCarotid PulseMore lateralMore lateral MedialMedialWavy, UndulantWavy, Undulant Forceful, BriskForceful, BriskDecrease with InspirationDecrease with Inspiration No changeNo changeIncrease in supine positionIncrease in supine position No changeNo changeIncrease with abdominal pressureIncrease with abdominal pressure No changeNo changeDouble PeakedDouble Peaked Single PeakSingle PeakObliterated with PressureObliterated with Pressure Cannot be ObliteratedCannot be ObliteratedBetter VisibleBetter Visible Better palpatedBetter palpatedBetter viewed from foot end of bedBetter viewed from foot end of bed

az MU

M

Levels of Clinical Examination in Heart Failure Patients

oLevel 1: quick look (e.g. pt dyspnoeic with minimal exertion?)

oLevel 2: essential heart failure examinationo General appearance, vital signso Jugular venous pressure, hepatojugular refluxo Ausculation of chest and precordialo Liver spano Peripheral oedema, perfusion

oLevel 3: comprehensive heart failure examination

Leier et Chatterjee. CHF 2007; 13: 41

az MU

M

Novel Symptom of Advanced Heart Failure – Bendopnoea

Thibodeau et al. JACC HF 2014; 2: 24

CardiacCardiac Index Index PulmPulm. . capillarycapillary wedgewedge pressurepressure Right Right atrialatrial pressurepressure

102 102 patientspatients withwith HFrEFHFrEF undergoingundergoing right right heartheart catheterisationcatheterisation

az MU

M

Clinical Examination of Congestion

oWhat do we do?o History / symptomso Clinical examination

oHow accurate are we in clinically examining congestion / heart failure?

oWhat does it tell us in addition?oConclusion

az MU

M

Probability of CHF

Wang et al. JAMA 2005; 294: 1944

if absentif absent

if absentif absent

if absentif absent

if presentif present

if presentif present

if presentif present

if presentif present

if absentif absent

az MU

M

Probability of CHF

Wang et al. JAMA 2005; 294: 1944

if absentif absent

if absentif absent

if absentif absent

if presentif present

if presentif present

if presentif present

if presentif present

if absentif absent

az MU

M

Diagnostic Accuracy of Clinical Findings in Primary Care

NYHA III

Orthopnoea

Nocturia

Loop d

iureticRale

s

Irreg

pulse

Displac

ed apex S3

Elevated

JVP

Akle sw

elling

0%

20%

40%

60%

80%

100%

Sensitivity Specificity

Kelder et al. Circulation 2011; 124: 2865

az MU

M

Framingham Criteria for Heart Failure (simplified)

Major criteria

o Acute pulmonary oedemao Cardiomegalyo HJRo Neck vein distentiono Orthopnoea or PNDo Raleso Third heart sound gallop

Minor criteria

o Ankle oedemao Dyspnoea on exertiono Hepatomegalyo Nocutural cougho Pleural effusiono Tachycardia (>120bmp)

Heart failure if two major criteria or one major and two minor are met.Heart failure if two major criteria or one major and two minor are met.High sensitivity / NPV and medium specificity / PPVHigh sensitivity / NPV and medium specificity / PPV

Rihal et al. Am J Cardiol 1995 // King et al. Am Fam Physician 2012; 85: 1161

az MU

M

Comparing Signs and Symptoms HFrEF versus HFpEF

Bhatia et al. NEJM 2006;355:260

az MU

M

Clinical Examination of Congestion

oWhat do we do?o History / symptomso Clinical examination

oHow accurate are we in clinically examining congestion / heart failure?

oWhat does it tell us in addition?oConclusion

az MU

M

Prognostic Value of Clinical Examination in Heart Failure

Drazner et al. N Engl J Med 2001; 345: 574

Data Data fromfrom the SOLVD treatment trial the SOLVD treatment trial

Elevated jugular venous pressureElevated jugular venous pressureAdjusted HR=1.30, p<0.005Adjusted HR=1.30, p<0.005

Third heart soundThird heart soundAdjusted HR=1.22, p<0.005Adjusted HR=1.22, p<0.005

At At the the time time of of enrollmentenrollment, , investigators investigators evaluated evaluated patients patients for for the the presence presence or or absence absence of of elevated elevated jugular jugular venous venous pressure pressure and and a a third third heart heart sound sound on on the basis of a the basis of a routine physical routine physical examination. examination. The The presence presence of of elevated elevated jugular jugular venous venous pressure pressure or or a a third third heart heart sound sound was was indicated indicated in in a a “yes” “yes” or or “no” “no” format.format.

az MU

M

Congestion at Discharge –Clinically Meaningful?

Signs / symptoms

0 1 2 3

Dyspnoea None Seldom Frequent Continuous

Orthopnoea None Seldom Frequent Continuous

Fatigue None Seldom Frequent Continuous

JVD (cm H2O) <6 6-9 10-15 >15

Rales None Bases To <50% >50%

Oedema Absent/trace slight Moderate Marked

Ambrosy et al. Eur Heart J 2013; 34: 835

WithWith higherhigher score, score, higherhigher BNP/NT- BNP/NT-proBNPproBNP, , lowerlower bloodblood pressurepressure, , lowerlower LVEF, LVEF, lowerlower sodiumsodium, , worseworse renalrenal functionfunction, , broaderbroader QRS, more QRS, more oftenoften previouslypreviously hospitalisedhospitalised, more co-, more co-morbiditiesmorbidities ( (renalrenal failure, diabetes, COPD, PVD) failure, diabetes, COPD, PVD)

az MU

M

Congestion at Discharge –Clinically Meaningful?

Ambrosy et al. Eur Heart J 2013; 34: 835

az MU

M

How Accurate Are We in Clinically Assessing Congestion?

o215 observations by 9 examiners in 116 consecutive patients undergoing right heart catherisation

oProspective estimation if normal or elevatedoAdded value of BNP and echocardiography

From et al. Am J Med 2011; 124: 1051

Right sided

Left sided

90%80%70%60%50%40%30%20%10%0%

Overall Staff TraineeWhat about BNP and echocardiography?

No added value!

az MU

M

Clinical Examination of Congestion

oHistory and clinical examination are still cornerstones in the evaluation of heart failure patients

oMuch more studies on the clinical value of technological examinations

oNot perfect, but reasonably accurate for diagnosis of heart failure and assessment of congestion

oIndependent prognostic valueoExperience matters Use it for the sake of your

patients