Joint Symposium of the HFSA and ACC

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




Clinical Congestion




Clinical Congestion




Biomarkers • Natriuretic peptides • Hemoconcentration

Implantable monitors

Blood volume

Clinical Congestion



Biomarkers Implantable monitors Blood volume

=

Outline


• Identify hemodynamic congestion – Key parameters (JVP)

– Dynamic maneuvers

• Prognostic utility of clinical congestion

Outline





“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 high Clinical 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



Concordant e.g., RA 11/PCWP 22


RAP/PCWP<1/3 “Preserved RV”


e.g., RA 5/PCWP 30


RAP/PCWP<1/3 “Preserved RV”

RAP/PCWP>2/3 “Right-Left Equalizer”


e.g., RA 18/PCWP 20 e.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 press N=366; Cleveland Clinic

Outline




• Hepatojugular reflux (HJR)

• Blood pressure response to Valsalva

• Bendopnea


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


Pulmonary capillary wedge pressure

Sitting Bending0

10

20

30

40

50

Position of subjectPu

lmo

na

ry c

ap

illa

ry w

ed

ge

pre

ssu

re,

mm

Hg

Bendopnea

No Bendopnea





Sitting Bending0

10

20

30

40

50


lmo

na

ry c

ap

illa

ry w

ed

ge

pre

ssu

re,

mm

Hg

Bendopnea

No BendopneaDyspnea threshold





Sitting Bending0

10

20

30

40

50


lmo

na

ry c

ap

illa

ry w

ed

ge

pre

ssu

re,

mm

Hg

Bendopnea

No BendopneaDyspnea threshold

Will Bendopnea Improve Clinical Assessment of Hemodynamics?

Outline





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 Score*

0 1 2 3-9


Death 19% 25% 25% 43%

HF hosp. or Death 36% 46% 46% 60%





Congestion Score*

0 1 2 3-9


Death 19% 25% 25% 43%

HF hosp. or Death 36% 46% 46% 60%




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, 2014 N = 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

Healthcare

Joint Symposium of the HFSA and ACC