sign in sign up
<<
Home , Cardiac examination, Ejection fraction

JACC Vol. 22 . No. 4 468. October 1993:%8-74

Bedside Cardiovascular Examination in Patients With Severe Chronic Failure: Importance of Rest or Inducible Jugtlar Venous Distension

SAMUEL M . BUTMAN, MD, FACC, GORDON A . EWY, MD, FACC, JAMES R. STANDEN, MD, KARL B. KERN, MD, FACC, ELIZABETH HAHN, MA Tucson, Arizona

O*edws. The aim of this study was to determine the sensi- jugular venous distension and the abdomhsojugular test, when tMty, speciddty and utility of the cardiovascular examination In positive, Indicated higher right heart pressures and lower mea- predicting cardiac In patients with odvanced sures of cardiac performance. The presence of jugular venous chronic congestive heart Were . distension, at rest or Inducible, had the best combination of i m xd. Although the physical signs of acute left heart sensitivity (81%), specificity (80%) and predictive accuracy (81%) failure have been shown to correlate relatively well with cardiac for elevation of the pulmonary capillary wedge pressure their reliability in estimating hemodynamics In (z18 mm Hg). Furthermore, In this population sample, the patio with chronic has recently bean questioned . probability of an elevated wedge pressure was 0 .96 when either Mf1lerils, We prsspecthily recorded the history, cardiovascu- variable was present. lar physical sigto present at bedside examination and the hessoa Conelnsions. The bedside cardiovascular examination in the dynamic measurements obtained at right heart catheterization in patient with chronic heart failure is extremely useful in identifying S2 patients with chronic congestive heart failure undergoing patients with elevation of right and left heart pressures . t xami- in-hospital evaluation for possible heart transplantation . In adds• nation for jugular venous distension at rest or by the abdomino . don, we obtained chest radiographs and mtdtigated nuclear scans jugular test Is simple and highly sensitive and specific In assessing lbr the evaluation of left ventricular function. left heart pressures In these patients. Rows. Pulmonary roles, a left ventricular third heart sound, (J Am Coll Ccrdiol 1993,22.40-74)

A thorough and are the hemodynamic measurements obtained at cardiac catheter- cornerstones in the diagnosis of patients with heart disease, ization . although the role of the physical examination in managing patients with chronic congestive heart failure is less clear (1-3). The physical signs for acute left heart failure have Methods been shown to correlate relatively well with hemodynamics, Patients . Fifty-two patients with chronic left ventricular but their reliability in estimating cardiac hemodynamics in dysfunction referred for evaluation for possible heart trans- patients with chronic heart failure has been questioned plantation were prospectively evaluated with a thorough (4-6). The abdominojugular test, perceived by many only as cardiovascular history and physical examination, upright an index of right heart function, is an easily mastered posteroanterior chest roentgenogram, right heart catheter- bedside sign of left heart dysfunction (7-9). We sought to ization and multigated radionuclide ventriculography study objectively evaluate the usefulness of specific variables of of the heart, all within 24 h of the physical examination. the cardiovascular examination, as well as the abdominojug- Twenty-seven patients (52%) had a repeat examination of ular test and chest roentgenogram, in patients with advanced the cardiorespiratory system on the same day as the initial chronic heart failure and to correlate these findings with examination by a second board-certified cardiologist, un- aware of the findings of the first examination . Medical therapy was unchanged during this period . Bedside examinations. Pulmonary or rales were From the Section of , Department of intema) and the recorded as present or absent . Jugular venous distension Department of Radiology. University of Arizona College of Medicine, Tuc- son, Arizona. was deemed present if venous pulsations were visible, with Manuscript received December 14, 1992; revised manuscript received the patient's head and thorax elevated at 45° from the February 22.1993, accepted March 31,1993. horizontal plane or if the venous pressure was estimated to Samuel M. Butman, MD, Cardiology P* *W Uti vanity Medical Center. 1501 North Campbell Avenue, Tucson, be >7 cm H2O (7,8). The abdominojugular test was graded Arizona $5734. as positive or negative according to criteria previously

01993 by the American College of Cardiology 0735-1097/93/$6.00

JACC Vol . 22. No . 4 K!TMAN ET At.. 969 October 1993 :968-74 CARDIAC EXAMINATION IN CHRONIC HEART FAILURE

published (9). In brief, a positive test was defined as eleva- logistic regression models, which utilized STATA software tion of mean with an abrupt fall of (Version 2 .05 . Computing Resource Center). ?4 cm with the release of 10 s of abdominal pressure . Each patient was told to breathe normally without straining . Firm abdominal pressure was applied for 10 s over the center of Results the patient's abdomen with the palm and fingers of the Most (94%) of the 52 patie, were male ; the mean age examiner's right hand . As part of each cardiovascular phys- was 53 .1 years (range 31 to 66). Patients had significant ical examination each observer recorded and limitation of activity (mean New York Heart Association pressure and the presence or absence of peripheral functional class Ill) ; orthopnea was present in 26 (50%) of and of third and fourth . the 52 patients and paroxysmal nocturnal dyspnea in 18 Hernodynamic measurements . Right heart catheterization (35%) within the preceding 2 weeks . Forty-two patients was performed percutaneously in all 52 patients from a (81%) were taking digitalis and 40 (77%) were taking an femoral vein with a balloon-tipped thermodilution triple- -converting enzyme inhibitor . Only 8 patients lumen catheter. Pressures were obtained using Statham (15%) had peripheral edema . In 47 patients (90%), cardio- fluid-filled transducers and recorded on an Electronics for megaly was evident on chest roentgenogram The mean left Medicine VR16 recorder . Pulmonary capillary wedge pres- ventricular ejection fraction, determined by multigated nu- sure was confirmed by fluoroscopy, typical waveform in all clear angiography, was 18 ± 6% (range 6% to 39%) . Twenty- and by saturation determinations in sonic cases . Cardiac seven patients (52%) had ischemic heat disease . There were output was determined by the thermodilution technique no significant differences in the follow ;ng analyses when the using the mean of three consecutive ice-cold water injec- patients were grouped by etiology of heart failure. There was no significant difference in heart rate or tions. Intraarterial pressures were obtained in the 14 patients obtained noninvasively or during the who also underwent left heart catheterization at the time of same day. the right heart catheterization and were compared with lntraobserver agreement . There was good agreement on values obtained by sphygmomanometry . After comparisons the reported physical findings in these patients, although of the means, the latter were used in the calculation of agreement did vary from 81% agreement for the presence or systemic . Standard formulas were used absence of a third heart sound (kappa = 0 .60, p = 0.007) to to calculate pulmonary and systemic vascular resistance . 97% concordance for the interpretation of the abdominojug- Chest radiography . Chest roentgenograms were initially ular test (kappa = 0 .92, p < 0.001) . There was also good interpreted by one of several academic radiologists and were agreement between the two observers for pulmonary rates read later by an experienced cardiovascular radiologist (88% overall agreement, kappa = 0.65, p = 0.0003) and for (J .R.S.) who was unaware of the hemodynamic data and the the presence or absence of abnormal jugular venous disten- initial radiologist's interpretation . The findings on chest sion at rest (85% concordance, kappa = 0 .69, p = 0.0001). radiographs were reported as a presence or absence of Comparison of the interpretation of the chest roentgeno- cardiomegaly (cardiothoracic ratio >0 .50), pulmonary vas- grams similarly revealed excellent agreement when they cular redistribution or interstitial . were read by a second radiologist unaware of the hemudy- Statistical methods. Comparisons between proportions namic values and initial interpretations . There was 91% were made using a two-tailed Fisher exact test . Comparisons agreement on subjective readings of cardiomegaly (kappaa = between groups were made using the Student t test for 0.48, p = 0.0004) and 95% agreement on interpretations for unpaired data, and the results are reported as the mean value the presence or absence of interstitial edema (kappa = 0 .83, ± I SD. The p values were adjusted for multiple paired p < 0.0001), but there was only 74% concordance in identi- comparisons. A kappa statistic was used to evaluate agree fying pulmonary vascular redistribution (kappa = 0 .50, p = ment between observers. A pulmonary capillary wedge 0.0003). The analyses that follow use only the readings by pressure 2:18 mm Hg was chosen to be of clinical relevance the radiologist who had no knowledge of the hemodynamic in the management of patients with chronic heart failure, values and initial interpretations. sensitivity and specificity, and predictive values were calcu- Clinical signs of congestive heart failure. Pulmonary lated using standard methods . To identify independent pre- rales. Pulmonary rales were present in only 9 (17%) of dictors of the pulmonary capillary wedge pressure as a the total group of 52 patients (Table 1 . Fig. 1); 9 (24%) of dichotomous or continuous end point, logistic and linear 37 patients with pulmonary capillary wedge pressure regression methods were used, respectively . Significant (p < 18 min Hg, and in none of the 15 patients with a pulmonary 0.10) physical and radiographic signs were first identified ,:s capillary wedge pressure <18 mm Hg (p < 0 .05). The univariate predictors ; multivariate models were then formu- presence of tales had a low sensitivity of 24%D but a speci- lated using a backward elimination technique . Variables ficity and a positive predictive value of 100% for a pulmo- were eliminated one at a time until all those remaining were nary capillary wedge pressure ;cl8 mm Hg. However, the significant at p < 0.05. SAS software (Release 6 .04, SAS negative predictive value of rales was very low (35%) . Institute) was used for all statistical analyses except for the Comparison of patients with and without rales revealed that

970 HUTMAN ET AL . JACC Vol . 22, No . 4 CARDIAC EXAMINATION IN CHRONIC HEART FAILURE October 1993 :968-74

Table 1. Relation Between Interstitial Rales and Pulmonary Table 2 . Relation Between the Presence of a Third Heart Sound Capillary Wedge Pressure in 52 Patients and Pulmonary Capillary Wedge Pressure

PCWP < 18 mm Hg PCWP >1S mm Hg PCWP < IS mm Hg PCWP >18 mm Hg

Rates present 0 9 S, present 4 25 Rates absent 15 28 S, absent 11 12

Sensitivity of roles for PCWP --l8 mm Hg 24% Sensitivity of S, for PCWP aa8 mm Hg 68% Specificity of absence of raks for PCWP 1110% Specificity of absence of S 9 for PCWP 73% <19 mm Hg

Rates Absent Rates Present S, Absent S, Present

Patients (no .) 43 9 Patients (no.) 23 29 Heart rate (bests/min) 82 .103A 96 .0 (15 .1)* Heart rate (beats/min) 75 .6 (10.9) 91 .6113 .1)* APm (mm Hg) 83 .4 (9.8) $5 .3 ((U) APm (mm Hg) 85 .7 (10.1) 82 .3 (8 .8) RA (mm Hg) 7 .6 (5 .0) 14.9 (5 .5)t RA (mm Hg) 6.0 (3 .e) 11,1 (6.1)1' PAm (mm Hg) 31 .7 (9 .0) 41 .614 .5)t PAm (mm Hg) 28.7 (9 .5) 37 .2 (6.9)' PCWP (mm Hg) 20 .1 (8 .3) 25.9 (5 .4)# PCWP (mm Hg) 16.9 (8,1) 25 .3 (7 .3)t Cl (liters/min per MI) 2 .6 (0.7) 2 .1(0 .6)' C( (Ilters/m)n per m) i .11 10 .6) ? .210.6)1 SVI (mt/mln per MI) 31 .101A 21 .6 (7 .2)# SVI (ml/min per in) 311,6 (10.6) 25 .1 (9.0)" LVEF (91) 18.7 (7,9) 13.0(6 .7)' LVEF C%) 23 .3 (7.7) 13 .2 (4 .6)t PVR (Wood U) 2.3 (0 .9) 3.4 (2 .1)' PVR J Wood U ) 2 .2 (1 .1) 2 .8 (1 .4) SVR (dynes•i emr') 1.212(293) 1,417 (348)" SVR (dynes•s•cm ") 1,171(264) 1 .308 (334) 'p < 0.05. tp < 0.0005 . *p < 0.005 . Values presented are number of 'p < 0.0005 . 'p < 0.005 . Values presented are number of patients or mean patients or mean (*SD) . APm = ; CI = ; (*SD). S, = third heart sound ; other abbreviations as in Table 1 . LVEF = radionuclide angiographic left ventricular ejection fraction ; PAm M mean pressure; PCWP'* mean pulmonary capillary wedge pressure : PVR = pulmonary vascular resistance ; RA = mean right atria) pressure; SVI = volume index; SVR systemic vascular resistance . capillary wedge pressure < 18 mm Hg (specificity 73%) (Table 2). Again, patients with a third heart sound had higher right-sided pressures and a lower cardiac index and left the presence of pulmonary tales was associated with signif- ventricular ejection fraction than did those without this icantly higher right-sided pressures and pulmonary capillary abnormality . wedge pressure and a lower cardiac index end left ventric- Jugular venous distension and ahdorninojugular test . ular ejection fraction. Elevation ofjugular venous pressure was seen in 22 (42%) of Third heart soand. A third heart sound was heard in 29 the 52 patients (Table 3); in 21 (57%) of 37 patients with a (56%) of 52 patients . It was heard in 25 (68%) of 37 patients pulmonary capillary wedge pressure 18 mm Hg and in 1 with a pulmonary capillary wedge pressure 18 mm Hg (7%) of 15 patients with pulmonary capillary wedge pressure (sensitivity 68%) and 4 (27%) of IS patients with a pulmonary <18 mm Hg (p < 0.001) . Compared with patients without elevated jugular venous pressure, those with elevated pres-

Flgure 1 . Pulmonary capillary wedge pressure (PCWP) measure- sure had significantly higher right-sided and pulmonary ments are reported in conjunction with the clinical presence or capillary wedge pressures, pulmonary vascular resistance absence of tales. Open circles = patients without pulmonary vales ; and systemic vahcular resistance, as well as a lower cardiac dosed tides = patients with vales. index and left ventricular ejection fraction .

40 0 A positive abdominojugular test was present in 33 (63%) o of the 52 patients, all 22 patients with elevated jugular 00 venous pressure and 11 without elevated jugular venous O .. pressure at rest . When used in combination with elevated 000 jugular venous pressure, the presence of either of these two bedside findings provided high sensitivity and specificity for the presence and absence of a significantly abnormal pulmo- nary capillary wedge pressure (Table 3) . Compared with the presence or absence of elevated jugular venous pressure at rest alone, the sensitivity of this combination for an abnor- mal pulmonary capillary wedge pressure increased from 57% o' to 81% for elevated jugular venous pressure alone, although No Rates Rates the specificity fell from 93% to 80% . However, the overall

JACC Vol . 22, No . 4 BUTMAN ET AL . 971 October 1993:968-74 CARDIAC EXAMINATION IN CHRONIC HEART FAiLURE

Table 3. Jugular Venous Distension (with or without a positive 40 0 abdominojugular test) and Pulmonary Capillary Wedge Pressure me PCWP <18 mm Hg PCWP >18 mm Hg =o 30 0 00 0 JVD absent 14 16 03 M 00 JVD present I 21 8~ 0 i 20 0 ., o Sensitivity of JVD for PCWP 57% 3 0 e ?18 mm Hg o8 a 0 Specificity of an absence 93% 10 080 ofJVD for PCWP 0 <18 mm Hg 080 Positive predictive value 95% of JVD -JVD -AJT -JVD -AJT •JVD -AJT Negative predictive value of 47% absence of JVD Figure 2 . Pulmonary capillary wedge pressure (PCWP) measure- Predictive accuracy of 67% ments are reported in relation to the clinical presence (+) or absence JVD for PCWP (-) of jugular venous distension (JVD) and the presence of a PCWP <18 mm Hg PCWP X18 mm Hg positive (+) or negative (-) abdominojugular test (AJT) . Open circles - patients without elevated jugular venous pressure and a -AJT, -JVD 12 7 negative abdominojugular test ; hatched circles = patients without +AJT or +JVD 3 3(1 elevated jugular venous pressure but with a positive abdominojug- ular test ; closed circles = patients with evidence of both elevated Sensitivity of AJTIJVD for 81% jugular venous pressure at rest in addition to a positive abdomino- PCWP ;i-18 min Ill; jugular lest . Specificity of AJT/.t'3D for 80% PCWP < 18 mm ;[&- Positive predictive 'slue of 91 further supported by the intermediate level of abnormal AJTIJVD signs hemodynamics between patients with and without evidence Negative predictive value of 63% of elevated jugular venous pressure at rest (Table 3, Fig . 2). the AJTIJVD signs Radiographic findings. Cardiomegaly on the standard Predictive accuracy of 81% posteroanterior chest radiograph was present in 48 (92%) of AJTIJVD the 52 patients . About half (52%) had evidence of pulmonary Hemodynamic Values vascular redistribution at the time of evaluation, and only 12 (23%) had evidence of interstitial edema (Table 4). The -AJT, -IVD -JVD, +AJT +JVD, +Ai r sensitivity of pulmonary vascular redistribution was 65% for Patients 19 I t 22 a pulmonary capillary wedge pressure g18 tom Hg, with a Age (yr) 53.9 (8.9) 53.6 (10.0) 52.1 (10 .4) specificity of 80% for a pulmonary capillary wedge pressure Heart rate (beatsimin) 79.0 (14 .2) 80.4 (10.6)' 91-4(141) " < 18 mm Hg. Interstitial edema was relatively specific (87%) Aft (mm Hg) 83.6 (11 .6) 82.6 (6.9) 84.2 (8.9) RA (mm Hg) 4.4 (2.4) 7.8 (4 .6)t 13.2 (5 .2)* for a high pulmonary capillary wedge pressure but not PAm (mm Hg) 26.3 (8.2) 32.4 (7 .0)t 40.1(5 .4)* sensitive (27%) in patients with chronic heart failure . Radio- PCWP (mm Hg) 14.9 (8 .5)t 21 .7 (5.2) 27.4 (5.8)" graphic evidence of pulmonary vascular redistribution was Cl (Gters/min per m2) 3.0(0.6)t 2.4 (0.6) 2.1 (0.5)* associated with significantly higher wedge pressures, as well SVI (ml/min per m2 ) 39.4 (11 .0) 31 .3 (10.6) 23.8 (7.8)* as other evidence of more compromised cardiac function. LVEF (4t;) 21 .9 (8.0) 17.8 (7.1) 14.0 (6.6)* Results of the univariate models to predict pulmonary PVR (Wood U) 1 .9 (0.7) 2.4(l .4) 3.1 (1 .4)* capillary wedge pressure as a continuous variable are shown SVR (dynes-s-cm" 5) 1 .070 (199) 1,301(350) 1,374 (306)* in Table 5 . In this group of patients, although the presence of For comparisons between columns I and 3, *p < 0.05 ; between columns rates, peripheral edema and other accepted physical signs of I and 2, tp < 0.05 ; between columns 2 and 3, tp < 0 .05 . Unless otherwise heist failure were highly correlated with the pulmonary indicated, values presented are number of patients or mean (±SD). -AJT, +AJT = negative and positive abdominojugular test, respectively ; -JVD and capillary wedge pressure, multivariate analysis revealed that +JVD = absence tad presence of jugular venous distension, respectively ; a positive abdominojugular test (with or without elevated other abbreviations as in Table 1 . jugular venous pressure), a third heart sound and radio- graphic vascular redistribution were the best independent predictors of pulmonary capillary wedge pressure. Using the predictive value of this combination over that of elevated regression model, the pulmonary capillary wedge pressure jugular venous pressure alone was increased from 67% for for a patient presenting without any of these three signs was elevated jugular venous pressure alone to 81% for the estimated as 12 mm Hg, whereas the pulmonary capillary presence of either elevated jugular venous pressure or a wedge pressure for a patient with all three was estimated as positive abdominojugular test. Furthermore, the hemody- 29 mm Hg. Results of the univariate r todels to predict a namic significance of a positive abdominojugular test is pulmonary capillary wedge pressure l8 mm Hg as a

9'72 BUTMAN ET AL . JACC Vol. 22, No . 4 CARDIAC EXA.5 MATION IN CHRONIC HEART FAILURE October 1993:968-74

Table 4. Radiographic Pulmonary Ch:,nges in Relation to the Table 5. Univariate Clinical Predictors of Pulmonary Capillary Pulmonary Capillary Wedge Pressure Wedge Pressure PCwP PCWP Physical/Radiographic Sign Coefficient (+ SE) P Value <18 mm Hg >18 mm Hg Rales 8 .7726 (2 .9668) 0.0047 Chest X-ray him JVD 9 .9303 (2 .0227) 0.0(M)I Redistribution 3 24 JVD/AJT 10 .5375 (2 .0401) 0.0001 No redistribution 12 13 Peripheral edema 8 .8413 (3 .3379) 0.0108 Mterstitial edema 2 10 S3 8 .3883 (2 .1431) 0.0003 Absence of edema 13 27 Heart rate 0 .2336 (0.0801) 0.0055 1 .0580 (0.4107) 0.0133 Sensitivity of redistribution for 65% Cardiomegaly 6 .9167 (4,4595) 0.1272 PCWP al$ mm Hg Vascular redistribution 10 .0044 (1 .9817) 0.001 Whieity of redistribution for 80% Interstitial edema 7 .0833 (2 .7(81) 0.0117 PCWP

JACC Vol . 22, No . 4 BUTMAN ET AL. 9'73 October 1993:968-74 CARDIAC EXAMINATION IN CHRONIC HEART FAILURE

larly sensitive, this sign was highly specific, and all nine of dysfunction, and the sensitivity and specificity of any test our patients with rates had a pulmonary capillary wedge are dependent on the population sample being studied (9,14). pressure >18 mm Hg and as a group, those with rales also However, this study does confirm the importance of jugular had significantly worse cardiac function (Table 1) . venous distension seen at rest or after provocation by the RadkIgraplly in chronic heart failure. Chronically high abdominal jugular test as an important clue to abnormal left-, left-sided heart pressures permit compensatory mechanisms as well as right-sided, hemodynamics . When patients with to correct the fluid shifts that have occurred, which then may chronic congestive heart failure do not have evidence of mask clinical and radiographic evidence of the underlying elevated jugular venous pressure at rest or inducible eleva- hemodynamic derangements. Increased lymphatic drainage tion of (that is, a positive abdomi- will clear flooded alveoli, and rates and radiographic evi- nojugular test) at the bedside, the mean pulmonary capillary dence of edema may be absent, as previously reported wedge pressure is not likely to be significantly elevated . This (10,11) . In the patient with chronic congestive heart failure, would support two hypothetic explanations for the apparent the chest radiograph is not as useful as it is in the patient with association between right- and left-sided cardiac hemody- acute (5). However, it can be used in namics in these patients : 1) the linking of increased sympa- the detection of clinically unrecognized heart failure . Heart thetic tone from left ventricular failure to increased venous failure may not be recognized in one quarter of the patients tone and 2) the suggestion that increased pulmonary vascular with radiographic evidence of interstitial edema and, con- volume is the cause of increasing signs of right heart failure versely, alveolar edema may only be seen in one third of in patients with left heart failure (9,15). patients with a pulmonary capillary wedge pressure of The addition of the abdominojugular test to the routine ?25 min Hg (12 .13). The detection of pulmonary vascular evaluation of jugular venous pressure at rest improves the redistribution was more accurate in estimating hemodynam- ability of the bedside examination to detect elevated pulmo- ics, although the presence of interstitial edema, although nary venous pressures and thereby assess left heart function . infrequent, was highly specific (Table 4) . Thus, the absence However, the results of the test must be interpreted in the of the commonly sought after signs of pulmonary rates or context of the patient's cardiovascular problem . In this crackles during physical examination and interstitial edema study, which did not include patients with valvular heart on chest roentgenograms are not reliable predictors of an disease, an elevated pulmonary capillary wedge pressure elevated pulmonary capillary wedge pressure in patients reflected increased left ventricular filling pressure . In a with chronic heart failure . previous study of unselected patients undergoing cardiac Jugular venous distension, known to be a reliable mea- catheterization (9), the results of the abdominojugular test sure of elevated right-sided pressures, has been used to correlated better with the presence of an elevated wedge predict pulmonary capillary wedge pressure (4-6) . How- pressure than with the presence of abnormal ventricular ever, we found that it more accurately predicted elevation of function or left ventricular filling pressure . For example, a the pulmonary capillary wedge pressure than the presence of patient with mitral regurgitation or mitral stenosis may have pulmonary rates (predictive accuracy of 67% vs . 46%, re- a normal left ventricular ejection fraction and left ventricular spectively), and patients with elevated jugular venous pres- filling pressure but have an elevated pulmonary capillary sure had significantly worse hemodynamics when compared wedge pressure . with those without elevated jugular venous pressure (Table Limitations of the study . One potential limitation of this 3). study is that the bedside examinations were not performed A positive abdominojugular test identified patients with simultaneously with the hemodynamic measurements . How- poorer hemodynamic status whether or not there was evi- ever, it is unlikely that the hemodynamic status changed dence of jugular venous distension at rest. Furthermore, in significantly in these patients with chronic heart failure who previous work, when a pulmonary capillary wedge pressure did not have significant changes in their medications or vital of 15 mm Hg was used as the cutoff point, only one patient signs. Another potential limitation is that the presence or with a positive abdominojugular test had a pulmonary cap- absence of a third heart sound was not documented by illary wedge pressure <15 mm Hg, confirming this bedside phonocardiography . However, there was good concordance test's usefulness in identifying the patient with elevation of between the assessment of examiners, and phonocardio- the pulmonary capillary wedge pressure (9) . When used in graphy is no longer used in clinical practice. combination with elevated jugular venous pressure as evi- Although this study was limited to patients referred for dence of light heart decompensation, these two measures of heart transplantation, these were not patients in extremis right-sided pressures provide high sensitivity and specificity and were representative of typical patients seen with signif- for the presence and absence of elevated pulmonary capil- icant cardiac dysfunction . lary wedge pressure (81% and 80%, respectively), with a Conclusions . The bedside clinical examination of the predictive accuracy of 81% . patient with chronic heart fail)=.re is extremely useful in and right heart Comparison of this study wish recent reports on the use of predicting significant elevation of both left the positive abdominojugular test is somewhat limited be- pressures, and previously considered clinical signs of right cause this study was confined to patients with severe cardiac heart failure are important in predicting left-sided pressures

974 BUTMAN ET AL . JACC Vol . 22 . No. 4 CARDIAC EXAMINATION IN CHRONIC HEART FAILURE October 1993 :968-•74

and the state of cardiac compensation. These results are 5. Forrester JS, Diamond GA, Swan HJC . Correlative classification of useful in the care of patients with documented significant left clinical and hemodynamic function after acute myocardial infarction . Am J Cardiol 1977 ;39:137-45 . ventricular systolic impairment . Further study is needed in 6. Chakko S. Woska D, Martinez H, et al. Clinical, radiographic, and patients with milder systolic dysfunction or those with hemodynamic correlation in chronic congestive heart failure : conflicting predorfrma.-t r rimtolic abnormalities . Early identification results may lead to inappropriate care . Am J Med 1991 ;90:353-9. of deco, -ri- ion Cats pr4vent the p:einaturc death of these 7. Ewy GA . Marcus Fl. Bedside estimation of venous pressure . Heart Bull 1965;17:41-4. high rig, pa:ien[s and y ii; facilitated by mcc!nition of the 5. Ewy GA. Venous and arterial pulsations . In: Horowitz LD, Groves BM, afolrnnenmkned %ifYi al signs t1 b} . These bedside techniques eds. Signs and Symptoms in Cardiology . Philadelphia: JB Lippincott, can he readily learned and relied on by the clinician. A better 1985 :132-55. understanding of these hemodynamic correlations should be 9. Ewy GA. The abdominojugular test: technique and hemodynamic corre- lates . Ann Intern Med 1988;109:456-60. helpful in the care of patients with chronic congestive heart 10 . Szidon JP, Pietro GG, Fishman AP . The alveolar-capillary membrane and Mire. pulmonary edema. N Engl I Med 1972 :286:1200-4. 11 . Staub NC, Nagano H, Pearce ML. Pulmonary edema in dogs, especially the sequence of fluid accumulation in lungs . J Appl Physiol 1967;22 :227- 40. References 12, Logue RB, Rogers JV, Gay BR . Subtle roentgenographic signs of left I. Mattleman SJ . Hakki AH . Iskandrian AS, Segal IJL, Kane SA . Reliability heart failure . Am Heart J 1963;63 :464-72. of bedside evaluation in determining left ventricular function : correlation 13. Dash H. Lipton MJ, Chatteijee K . Parmicy WW. Estimation of pulmo- with left ventricular ejection fraction determined by radionuclide ven. nary artery wedge pressure from chest radiograph in patients with chronic triculography . J Am Coll Cardiol 1983 :1 :417-20. congestive and , Br Heart J 2. Marente PR . Tobin JN . Wussertheil-Smolder S, et al. The relationship 1980 :44 :322-9. between left ventricular systolic function and congestive heart failure 14, Sochowski RA . Dubbin 3D, Naqvi SZ. Clinical and hemodynamic assess- diagnosed by clinical criteria . Circulation 1988 :77:607-12. ment of the hepatojugular reflux . Am J Cardiol 1990 ;66:1002-6. 3 . Harian Wit, Oberman A. Grimm It. Rosati RA. Chronic congestive heart IS . Ducas J, Wilder S, McGregor M . Validity of the hepatojugular reflux as failure in coronary artery disease: clinical criteria, Ann Intern Med a clinical test for congestive heart failure . Am J Cardiol 1983 ;52 :1299-303 . 1977:86:133-8. 16. Stevenson LW, Tilliisch JH. Hamilton M . et al . Importance of hemody- 4. Stevenson LW . Perloff JK, The limited reliability or physical signs for namic response to therapy in pre licting survival with ejection fraction estimating hemodynamics in chronic heart failure. JAMA 1989 :261 : s2O% secondary to ischemic or non-isehemic . 884-8. Am J Cardiol 1990;66 :1348-54.