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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
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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
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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
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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
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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?
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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
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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
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General Clinical Examination
oHeart rate: frequency / regularity?oBlood pressure: hypertension / hypotensionoAnaemic?oCyanotic?oObese / cachectic?oScars?
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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
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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?
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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)
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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!
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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