Comparison of estimates of right atrial pressure by physical examination and echocardiography in patients with congestive heart failure and reasons for discrepancies

Venous excess ultrasonography (VExUS) captures dynamic changes in volume status surrounding hemodialysis: A multicenter prospective observational study

Background

The evaluation of volume status is essential to clinical decision-making, yet multiple studies have shown that physical exam does not reliably estimate a patient's intravascular volume. Venous excess ultrasound score (VExUS) is an emerging volume assessment tool that utilizes inferior vena cava (IVC) diameter and pulse-wave Doppler waveforms of the portal, hepatic and renal veins to evaluate venous congestion. A point-of-care ultrasound exam initially developed by Beaubein-Souligny et al., VExUS represents a reproducible, non-invasive and accurate means of assessing intravascular congestion. VExUS has recently been validated against RHC-the gold-standard of hemodynamic evaluation for volume assessment. While VExUS scores were shown to correlate with elevated cardiac filling pressures (i.e., right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP)) at a static point in time, the ability of VExUS to capture dynamic changes in volume status has yet to be elucidated. We hypothesized that paired VExUS examinations performed before and after hemodialysis (HD) would reflect changes in venous congestion in a diverse patient population.

Methods

Inpatients with end-stage renal disease undergoing intermittent HD were evaluated with transabdominal VExUS and lung ultrasonography before and following HD. Paired t-tests were conducted to assess differences between pre-HD and post-HD VExUS scores, B-line scores and dyspnea scores.

Results

Fifty-six patients were screened for inclusion in this study. Ten were excluded due to insufficient image quality or incomplete exams, and forty-six patients (ninety-two paired ultrasound exams) were included in the final analysis. Paired t-test analysis of pre-HD and post-HD VExUS scores revealed a mean VExUS grade change of 0.82 (p<0.001) on a VExUS scale ranging from 0 to 4. The mean difference in B-line score following HD was 0.8 (p=0.001). There was no statistically significant difference in subjective dyspnea score (p=0.41).

Conclusions

Large-volume fluid removal with HD was represented by changes in VExUS score, highlighting the utility of the VExUS exam to capture dynamic shifts in intravascular volume status. Future studies should evaluate change in VExUS grade with intravenous fluid or diuretic administration, with the ultimate goal of evaluating the capacity of a standardized bedside ultrasound protocol to guide inpatient volume optimization.

Estimation of Right Atrial Pressure by Ultrasound-Assessed Jugular Vein Distensibility in Patients With Heart Failure

BACKGROUND

Clinical evaluation of central venous pressure is difficult, depends on experience, and is often inaccurate in patients with chronic advanced heart failure. We assessed the ultrasound-assessed internal jugular vein (JV) distensibility by ultrasound as a noninvasive tool to identify patients with normal right atrial pressure (RAP ≤7 mm Hg) in this population.

METHODS

We measured JV distensibility as the Valsalva-to-rest ratio of the vein diameter in a calibration cohort (N=100) and a validation cohort (N=101) of consecutive patients with chronic heart failure with reduced ejection fraction who underwent pulmonary artery catheterization for advanced heart failure therapies workup.

RESULTS

A JV distensibility threshold of 1.6 was identified as the most accurate to discriminate between patients with RAP ≤7 versus >7 mm Hg (area under the receiver operating characteristic curve, 0.74 [95% CI, 0.64-0.84]) and confirmed in the validation cohort (receiver operating characteristic, 0.82 [95% CI, 0.73-0.92]). A JV distensibility ratio >1.6 had predictive positive values of 0.86 and 0.94, respectively, to identify patients with RAP ≤7 mm Hg in the calibration and validation cohorts. Compared with patients from the calibration cohort with a high JV distensibility ratio (>1.6; n=42; median RAP, 4 mm Hg; pulmonary capillary wedge pressure, 11 mm Hg), those with a low JV distensibility ratio (≤1.6; n=58; median RAP, 8 mm Hg; pulmonary capillary wedge pressure, 22 mm Hg; P<0.0001 for both) were more likely to die or undergo a left ventricular assist device implant or heart transplantation (event rate at 2 years: 42.7% versus 18.2%; log-rank P=0.034).

CONCLUSIONS

Ultrasound-assessed JV distensibility identifies patients with chronic advanced heart failure with normal RAP and better outcomes.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03874312.

Implication of Right Atrial Pressure Estimated by Echocardiography in Patients with Severe Tricuspid Regurgitation

BACKGROUND

Little is known about how tightly right atrial pressure (RAP) is associated with prognosis in patients with severe tricuspid regurgitation (TR). The aim of this study was to investigate the association of RAP estimated by echocardiography (RAP-echo) with cardiovascular events in patients with severe TR.

METHODS

Two hundred forty outpatients (median age, 75 years; 130 women) who underwent two-dimensional transthoracic echocardiography and were diagnosed with severe TR were retrospectively studied. According to RAP-echo using the diameter of the inferior vena cava and its response to a sniff, patients were classified into two groups: low or middle and high RAP-echo. Cardiovascular events were defined as cardiovascular death and admission for heart failure.

RESULTS

During follow-up (median, 428 days; range, 87-1,229 days), 64 patients experienced cardiovascular events. By multivariate analysis, high RAP-echo was independently associated with cardiovascular events (hazard ratio, 2.46; 95% CI, 1.17-5.18). Also, jugular venous distention and leg edema were not independently associated with cardiovascular events.

CONCLUSIONS

The significant and stronger association of RAP-echo with clinical outcome compared with estimates of RAP on physical examination suggests that recognition of high RAP-echo can be a valuable surrogate for the clinical management of severe TR patients.

Variation in Hemodynamic Assessment and Interpretation: A Call to Standardize the Right Heart Catheterization

BACKGROUND

Invasive hemodynamic measurement via right heart catheterization has shown divergent data in its role in the treatment of patients with heart failure (HF) and cardiogenic shock. We hypothesized that variation in data acquisition technique and interpretation might contribute to these observations. We sought to assess differences in hemodynamic acquisition and interpretation by operator subspecialty as well as level of experience.

METHODS AND RESULTS

Individual-level responses to how physicians both collect and interpret hemodynamic data at the time of right heart catheterization was solicited via a survey distributed to international professional societies in HF and interventional cardiology. Data were stratified both by operator subspecialty (HF specialists or interventional cardiologists [IC]) and operator experience (early career [≤10 years from training] or late career [>10 years from training]) to determine variations in clinical practice. For the sensitivity analysis, we also look at differences in each subgroup. A total of 261 responses were received. There were 141 clinicians (52%) who self-identified as HF specialists, 99 (38%) identified as IC, and 20 (8%) identified as other. There were 142 early career providers (54%) and late career providers (119 [46%]). When recording hemodynamic values, there was considerable variation in practice patterns, regardless of subspecialty or level of experience for the majority of the intracardiac variables. There was no agreement or mild agreement among HF and IC as to when to record right atrial pressures or pulmonary capillary wedge pressures. HF cardiologists were more likely to routinely measure both Fick and thermodilution cardiac output compared with IC (51% vs 29%, P < .001), something mirrored in early career vs later career cardiologists.

CONCLUSIONS

Significant variation exists between the acquisition and interpretation of right heart catheterization measurements between HF and IC, as well as those early and late in their careers. With the growth of the heart team approach to management of patients in cardiogenic shock, standardization of both assessment and management practices is needed.

Systemic Venous Congestion Reviewed

Accurate determination of intravascular volume status is challenging in acutely ill patients. Favorable patient outcome is vital to correctly identify intravascular volume depletion and avoid systemic venous congestion. Most of the conventional means of hemodynamic monitoring in the acute healthcare setting are geared toward addressing the cardiac output and maintaining an optimum mean arterial pressure. While assessing and maintaining cardiac output in an acutely ill patient is very important, a venous congestion cascade is often overlooked, which can negatively affect the intraabdominal end organs. The prospect of using point-of-care ultrasound (POCUS) to determine systemic venous congestion could be a potentially handy tool for clinicians. Venous excess ultrasound score (VExUS) has also been utilized by clinicians as a semi-quantitative assessment tool to assess fluid status. This review aims to discuss the potential role of POCUS and VExUS scores in determining systemic venous congestion through a narrative review of recently published literature.

Association of peripheral venous pressure with adverse post-discharge outcomes in patients with acute heart failure: a prospective cohort study

AIMS

Congestion is the major cause of hospitalization for heart failure (HF). Traditional bedside assessment of congestion is limited by insufficient accuracy. Peripheral venous pressure (PVP) has recently been shown to accurately predict central venous congestion. We examined the association between PVP before discharge and post-discharge outcomes in hospitalized patients with acute HF.

METHODS AND RESULTS

Bedside PVP measurement at the forearm vein and traditional clinical examination were performed in 239 patients. The association with the primary composite endpoint of cardiovascular death or HF hospitalization and the incremental prognostic value beyond the established HF risk score was examined. The PVP correlated with peripheral oedema, jugular venous pressure, and inferior vena cava diameter, but not with brain-type natriuretic peptide. The 1-year incidence of the primary outcome measure in the first, second, and third tertiles of PVP was 21.4, 29.9, and 40.7%, respectively (log-rank P = 0.017). The adjusted hazard ratio of PVP per 1 mmHg increase for the 1-year outcome was 1.08 [95% confidence interval (1.03-1.14), P = 0.004]. When added onto the Meta-Analysis Global Group in Chronic HF risk score, PVP significantly increased the area under the receiver-operating characteristic curve for predicting the outcome [from 0.63 (0.56-0.71) to 0.70 (0.62-0.77), P = 0.02), while traditional assessments did not. The addition of PVP also yielded significant net reclassification improvement [0.46 (0.19-0.74), P < 0.001].

CONCLUSION

The PVP at discharge correlated with prognosis. The results warrant further investigation to evaluate the clinical application of PVP measurement in the care of HF.

TRIAL REGISTRATION NUMBER

UMIN000034279.

The Conundrum of Volume Status Assessment: Revisiting Current and Future Tools Available for Physicians at the Bedside

Assessment of patients’ volume status at the bedside is a very important clinical skill that physicians need in many clinical scenarios. Hypovolemia with hypotension and tissue under-perfusion are usually more alarming to physicians, but hypervolemia is also associated with poor outcomes, making euvolemia a crucial goal in clinical practice. Nevertheless, the assessment of volume status can be challenging, especially in the absence of a gold standard test that is reliable and easily accessible to assist with clinical decision-making. Physicians need to have a broad knowledge of the individual non-invasive clinical tools available for them at the bedside to evaluate volume status. In this review, we will discuss the strengths and limitations of the traditional tools, which include careful history taking, physical examination, and basic laboratory tests, and also include the relatively new tool of point-of-care ultrasound.

Burden of Heart Failure Signs and Symptoms, Prognosis, and Response to Therapy: The PARAGON-HF Trial

OBJECTIVES

This study investigated the prognostic importance of heart failure (HF) signs and symptoms in patients with heart failure and preserved ejection fraction (HFpEF), and the effect of sacubitril/valsartan on HF signs and symptoms.

BACKGROUND

In patients with HFpEF, worsening of HF symptoms, as a marker of cardiac decompensation, is frequently the reason for hospitalization. In this heterogenous disease entity, the prognostic value of HF signs and symptoms with regard to cardiovascular (CV) outcomes is poorly defined.

METHODS

The authors examined the association between baseline HF signs and symptoms (rest dyspnea, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, fatigue, edema, jugular venous distension, rales, and third heart sound) as well as burden of these HF signs and symptoms (classified as ≤2 and ≥3 HF signs and symptoms) and the primary composite of total HF hospitalizations and CV death, its components, and all-cause death in 4,725 patients enrolled in PARAGON-HF (Prospective Comparison of ARNI With ARB Global Outcomes in HFpEF) with available signs and symptoms at randomization. Response to sacubitril/valsartan on the basis of the presence of signs and symptoms was evaluated. Effects of sacubitril/valsartan on signs and symptoms over time were assessed using binary repeated-measures logistic regression.

RESULTS

Patients with high (≥3) burden of HF signs and symptoms (n = 1,772 [38%]) were more commonly women, had slightly lower left ventricular ejection fractions, higher body mass index, and more advanced New York Heart Association functional class compared with patients with low (≤2) burden (n = 2,953 [62%]) (p < 0.001 for all). Levels of N-terminal pro-B-type natriuretic peptide did not differ significantly between groups (p = 0.14). Greater burden of signs and symptoms was associated with higher risk for total HF hospitalizations and CV death (rate ratio [RR]: 1.50; 95% confidence interval [CI]: 1.30 to 1.74) and all-cause death (RR: 1.41; 95% CI: 1.21 to 1.65). Among individual signs and symptoms, orthopnea (RR: 1.29; 95% CI: 1.04 to 1.61) and rales (RR: 1.52; 95% CI: 1.10 to 2.10) were most predictive of the primary endpoint. Treatment response to sacubitril/valsartan was not significantly modified by burden of HF signs and symptoms (p for interaction = 0.08), though patients with orthopnea appeared to derive greater benefit from sacubitril/valsartan (RR: 0.67; 95% CI: 0.49 to 0.90) than those without orthopnea (RR: 0.97; 95% CI: 0.82 to 1.14; p for interaction = 0.04). Compared with valsartan, sacubitril/valsartan did not significantly decrease overall burden of HF signs and symptoms over time (odds ratio: 0.84; 95% CI: 0.67 to 1.07) but did reduce exertional dyspnea (odds ratio: 0.76; 95% CI: 0.63 to 0.93).

CONCLUSIONS

High burden of HF signs and symptoms, particularly the presence of orthopnea and rales, portends a higher risk for adverse CV events in patients with HF with preserved ejection fraction. Sacubitril/valsartan did not significantly decrease the burden of HF signs and symptoms over time but did reduce exertional dyspnea relative to valsartan. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).

Fluid overload in patients undergoing TAVR: what we can learn from the nephrologists

Aims

Fluid overload (FO) puts aortic stenosis (AS) patients at risk for heart failure (HF) and death. However, conventional FO assessment, including rapid weight gain, peripheral oedema, or chest radiography, is inaccurate. Bioelectrical impedance spectroscopy (BIS) allows objective and reproducible FO quantification, particularly if clinically unapparent. It is used in dialysis patients to establish dry weight goals. BIS has not been tested for prognostication in AS. This study aimed to evaluate whether BIS adds prognostic information in stable patients undergoing transcatheter aortic valve replacement (TAVR).

Methods and results

Consecutive patients scheduled for TAVR underwent BIS in addition to echocardiographic, clinical, and laboratory assessment. On BIS, mild FO was defined as >1.0 L and severe as >3.0 L. Combined HF hospitalization and/or all‐cause death was defined as primary endpoint. Three hundred forty‐four patients (81.5 ± 7.2 years old, 47.4% female) were prospectively included. FO by BIS was associated with clinical congestion signs, higher serum markers of cardiac injury, poorer left ventricular function, higher pulmonary pressures, and more severe tricuspid regurgitation (all P < 0.05). Yet, clinical examination was unremarkable in >30% in mild FO, only detected by BIS. During 12.1 ± 5.5 months, 67 (19.5%) events were recorded (40 deaths, 15 HF hospitalizations, and 12 both). Quantitatively, every 1 L increase in FO was associated with a 24% (HR 1.24, 95% CI 1.13–1.35, P < 0.001) increase in event hazard. This association persisted after adjustment for STS/EuroSCORE‐II, NT‐proBNP, left ventricular ejection fraction, and renal function.

Conclusions

In patients undergoing TAVR, FO by BIS is strongly associated with adverse outcomes. BIS measurement conveys prognostic information not represented in any currently used AS/TAVR risk assessments.

Relation of Peripheral Venous Pressure to Central Venous Pressure in Patients With Heart Failure, Heart Transplant, and Left Ventricular Assist Device

Peripheral venous pressure (PVP) monitoring is a noninvasive method to assess volume status. We investigated the correlation between PVP and central venous pressure (CVP) in heart failure (HF), heart transplant (HTx), and left ventricular assist device (LVAD) patients undergoing right heart catheterization (RHC). A prospective, cross-sectional study examining PVP in 100 patients from October 2018 to January 2020 was conducted. The analysis included patients undergoing RHC admitted for HF, post-HTx monitoring, or LVAD hemodynamic testing. Sixty percent of patients had HF, 30% were HTx patients, and 10% were LVAD patients. The mean PVP was 9.4 ± 5.3 mm Hg, and the mean CVP was 9.2 ± 5.8 mm Hg. The PVP and CVP were found to be highly correlated (r = 0.93, p < 0.00001). High correlation was also noted when broken down by HF (r = 0.93, p < 0.00001), HTx (r = 0.93, p < 0.00001), and LVAD groups (r = 0.94, p < 0.00005). In conclusion, there is a high degree of correlation between PVP and CVP in HF, HTx, and LVAD patients. PVP measurements can be used as a rapid, reliable, noninvasive estimate of volume status in these patient populations.

Impact of right ventricular stroke work index on predicting hospital readmission and functional status of patients with advanced heart failure

INTRODUCTION AND AIMS

The prognosis of chronic heart failure with reduced ejection fraction (HFrEF) has been studied extensively, but factors predicting cardiac decompensation are poorly defined. Right ventricular stroke work index (RVSWI), an invasive measure of right ventricular (RV) systolic function, is a well-known prognostic marker of RV failure after left ventricular assist device insertion and after lung transplantation. Thus, the aim of this study was to assess whether there is a relationship between RVSWI, HFrEF hospital readmission due to cardiac decompensation, and prognosis.

METHODS

We prospectively enrolled 132 consecutive patients with HFrEF. Right heart catheterization was performed and RVSWI values were calculated in all patients. The relationship between RVSWI values and readmission and prognosis was analyzed.

RESULTS

During a median follow-up of 20±7 months, 33 patients were readmitted due to cardiac decompensation in the survivor group, and 18 patients died due to cardiac causes. There was no difference between patients who died and survived in terms of RVSWI values. Among patients with decompensation, mean RVSWI was significantly lower than in patients with stable HFrEF (6.0±2.2 g/m²/beat vs. 8.8±3.5 g/m²/beat, p<0.001). On correlation analysis, RVSWI was negatively correlated with NYHA functional class. RVSWI was also identified as an independent risk factor for cardiac decompensation in Cox regression survival analysis.

CONCLUSIONS

We showed that RVSWI predicts cardiac decompensation and correlates with functional class in advanced stage HFrEF. Our data suggest the value of combining information on right heart hemodynamics with assessment of RV function when defining the risk of patients with advanced HFrEF.

A novel noninvasive method for remote heart failure monitoring: the EuleriAn video Magnification apPLications In heart Failure studY (AMPLIFY)

Current remote monitoring devices for heart failure have been shown to reduce hospitalizations but are invasive and costly; accurate non-invasive options remain limited. The EuleriAn Video Magnification ApPLications In Heart Failure StudY (AMPLIFY) pilot aimed to evaluate the accuracy of a novel noninvasive method that uses Eulerian video magnification. Video recordings were performed on the neck veins of 50 patients who were scheduled for right heart catheterization at the Palo Alto VA Medical Center. The recorded jugular venous pulsations were then enhanced by applying Eulerian phase-based motion magnification. Assessment of jugular venous pressure was compared across three categories: (1) physicians who performed bedside exams, (2) physicians who reviewed both the amplified and unamplified videos, and (3) direct invasive measurement of right atrial pressure from right heart catheterization. Motion magnification reduced inaccuracy of the clinician assessment of central venous pressure compared to the gold standard of right heart catheterization (mean discrepancy of −0.80 cm H₂O; 95% CI −2.189 to 0.612, p = 0.27) when compared to both unamplified video (−1.84 cm H₂O; 95% CI −3.22 to −0.46, p = 0.0096) and the bedside exam (−2.90 cm H₂O; 95% CI −4.33 to 1.40, p = 0.0002). Major categorical disagreements with right heart catheterization were significantly reduced with motion magnification (12%) when compared to unamplified video (25%) or the bedside exam (27%). This novel method of assessing jugular venous pressure improves the accuracy of the clinical exam and may enable accurate remote monitoring of heart failure patients with minimal patient risk.

Bedside hand vein inspection for noninvasive central venous pressure assessment

Rapid estimates of the central venous pressure (CVP) can be helpful to administer early fluid therapy or to manage cardiac preload in intensive care units, operating rooms or emergency rooms in order to start and monitor an adequate medical therapy. Invasive CVP measurements have inherent and non-negligible complication rates as well as great expenditures. Several noninvasive methods of CVP measurements, like ultrasound-guided techniques, are available, but require trained skills and special equipment which might not be at hand in all situations. Our purpose was to evaluate the feasibility and accuracy of CVP estimates assessed upon the height of hand veins collapse (HVC) using invasively measured CVP as the gold standard. The HVC was determined by slowly lifting the patient's hand while watching the dorsal hand veins to collapse. The vertical distance from the dorsal hand to a transducer air zero port was noted and converted to mmHg. The observer was blinded to the simultaneously measured CVP values, which were categorized as low (<7 mmHg), normal (7-12 mmHg) and high (>12 mmHg). Measurements were performed in 82 patients who had a median [IQR] age of 67 [60;74]. Median CVP was 12 [8;15] mmHg and the median absolute difference between the measured HVC and CVP was 4 [2;7] mmHg. The Spearman correlation coefficient between CVP and HVC was 0.55, 95%-CI [0.35;0.69]. Overall CVP categorization was correct in 45% of the cases. HVC had a sensitivity of 92% for a low CVP with a negative predictive value of 98%. A high HVC had a sensitivity of 29% but a high specificity of 94% for a high CVP. The overall performance of observing the hand vein collapse to estimate CVP was only moderate in the intensive care setting. However, the median difference to the CVP was low and HVC identifies a low CVP with a high sensitivity and excellent negative predictive value.

A Prospective Evaluation of the Diagnostic Accuracy of the Physical Examination for Pulmonary Hypertension

BACKGROUND

The usefulness of physical examination findings for pulmonary hypertension (PH) is not well established. The purpose of this study was to evaluate prospectively the diagnostic performance of the physical examination for detecting PH.

METHODS

Consecutive patients undergoing right-sided heart catheterization (n = 116) were examined by an attending physician, medical resident, and medical student in a blinded fashion. Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated for each physical finding. Jugular venous pulsation (JVP) height was compared with right atrial pressure (RAP) by using linear regression. The association between physical findings and PH was assessed using univariate and multivariate logistic regression.

RESULTS

The prevalence of PH was 87%. Only a JVP > 3 cm (positive LR, 2.5; 95% CI, 1.2-5.4) and pulmonic regurgitation murmur (specificity, 100%; 95% CI, 79%-100%) helped rule in PH. The absence of JVP > 3 cm (negative LR, 0.4; 95% CI, 0.3-0.6) and absence of loud pulmonic component of the second heart sound (negative LR, 0.5; 95% CI, 0.3-0.9) had modest usefulness in excluding PH. JVP correlated with RAP (r = 0.59; P < .001) but tended to lead to underestimation of RAP (mean bias, -3.4 cm H₂O; 95% limits of agreement, -14.0 to 7.2). The presence of JVP > 3 cm and a parasternal heave discriminated PH (area under the curve [AUC] = 0.75). The combination of JVP > 3 cm, heave, and peripheral edema discriminated severe PH (mean pulmonary arterial pressure ≥ 45 mm Hg; AUC = 0.82).

CONCLUSIONS

Individual physical examination findings have inadequate diagnostic usefulness for PH. No combination of findings can be used to exclude PH, but the presence of high JVP, peripheral edema, and parasternal heave suggests severe PH.

Performance of Noninvasive Assessment in the Diagnosis of Right Heart Failure After Left Ventricular Assist Device

Right heart failure (RHF) after left ventricular assist device (LVAD) is associated with poor outcomes. Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) defines RHF as elevated right atrial pressure (RAP) plus venous congestion. The purpose of this study was to examine the diagnostic performance of the noninvasive Intermacs criteria using RAP as the gold standard. We analyzed 108 patients with LVAD who underwent 341 right heart catheterizations (RHC) between January 1, 2006, and December 31, 2013. Physical exam, echocardiography, and laboratory data at the time of RHC were collected. Conventional two-by-two tables were used and missing data were excluded. The noninvasive Intermacs definition of RHF is 32% sensitive (95% cardiac index (CI), 0.21-0.44) and 97% specific (95% CI, 0.95-0.99) for identifying elevated RAP. Clinical assessment failed to identify two-thirds of LVAD patients with RAP > 16 mm Hg. More than half of patients with elevated RAP did not have venous congestion, which may represent a physiologic opportunity to mitigate the progression of disease before end-organ damage occurs. One-quarter of patients who met the noninvasive definition of RHF did not actually have elevated RAP, potentially exposing patients to unnecessary therapies. In practice, if any component of the Intermacs definition is present or equivocal, our data suggest RHC is warranted to establish the diagnosis.

Korean Guidelines for Diagnosis and Management of Chronic Heart Failure

The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea. 
The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.

Assessment of inferior vena cava diameter by echocardiography in normal Indian population: A prospective observational study

BACKGROUND

The assessment of the IVC diameter is self explanatory for evaluation of the individuals' volume status. Studies regarding IVC diameter estimation in normal individuals are scarce.

AIM

The present study aimed to define normal criteria of size and dynamics of the inferior vena cava (IVC) by M-mode echocardiography in normal individuals.

METHODS

This was a prospective, single-center, observational study carried out at Sri Jayadeva Institute of Cardiovascular Sciences and Research between December 2011 and April 2014. A total of 4126 consecutive individuals were enrolled. Normal IVC diameter was measured both during inspiration and expiration by M-mode echocardiography in subcostal view.

RESULTS

The IVC diameter varied from 0.46 to 2.26cm in the study individuals. The IVC diameter ranged from 0.97 to 2.26cm during expiration and from 0.46 to 1.54cm during inspiration. A strong correlation was observed between IVC diameter and height, weight and BMI of the individuals, calculated using Pearson correlation. The correlation coefficients for expiratory and inspiratory IVC diameters as a function of BMI were 0.686 and 0.7, respectively.

CONCLUSIONS

Our findings corroborate the correlations between height, weight and BMI with IVC diameter. Future studies could be focused to bring about a steadfast formula for calculating IVC diameter based on demographic parameters of an individual.

Assessment and Management of Volume Overload and Congestion in Chronic Heart Failure: Can Measuring Blood Volume Provide New Insights?

BACKGROUND

Volume overload and fluid congestion remain primary clinical challenges in the assessment and management of patients with chronic heart failure (HF).

SUMMARY

The pathophysiology of volume regulation is complex, and the simple concept of passive intravascular fluid accumulation is not adequate. The dynamics of interstitial and intravascular fluid compartment interactions and fluid redistribution from venous splanchnic beds to the central pulmonary circulation need to be taken into account in strategies of volume management. Clinical bedside evaluations and right heart hemodynamic assessments can alert of changes in volume status, but only the quantitative measurement of total blood volume can help identify the heterogeneity in plasma volume and red blood cell mass that are features of volume overload in chronic HF. The quantitative assessment of intravascular volume is an effective tool to help guide individualized, appropriate therapy.

KEY MESSAGE

Not all volume overload is the same, and the measurement of intravascular volume identifies heterogeneity to guide tailored therapy.

Symptoms and Signs of Heart Failure at Admission and Discharge and Outcomes in the Sub-Saharan Acute Heart Failure (THESUS-HF) Registry

BACKGROUND

Symptoms and signs of heart failure (HF) are the most common reasons for admission to hospital for acute HF (AHF) and are used routinely throughout admission to assess the severity of disease and response to therapy.

METHODS AND RESULTS

The data were collected in The Sub-Saharan Africa Survey on Heart Failure (THESUS-HF) study, a prospective, multicenter, observational survey of AHF from 9 countries in sub-Saharan Africa. A total of 1006 patients, ≥12 years of age, hospitalized for AHF were recruited. Symptoms and signs of HF and changes in dyspnea and well-being, relative to admission, were assessed at entry and on days 1, 2, and 7 (or on discharge if earlier) and included oxygen saturation, degree of edema and rales, body weight, and level of orthopnea. The patient determined dyspnea and general well-being, whereas the physician determined symptoms and signs of HF, as well as improvements in vital sign measurement, throughout the admission. After multivariable adjustment, baseline rales and changes to day 7 or discharge in general well-being predicted death or HF hospitalization through day 60, and baseline orthopnea, edema, rales, oxygen saturation, and changes to day 7 or on discharge in respiratory rate and general well-being were predictive of death through day 180.

CONCLUSIONS

In AHF patients in sub-Saharan Africa, symptoms and signs of HF improve throughout admission, and simple assessments, including edema, rales, oxygen saturation, respiratory rate, and asking the patient about general well-being, are valuable tools in patients' clinical assessment.

Fluid Volume Overload and Congestion in Heart Failure

Volume regulation, assessment, and management remain basic issues in patients with heart failure. The discussion presented here is directed at opening a reassessment of the pathophysiology of congestion in congestive heart failure and the methods by which we determine volume overload status. Peer-reviewed historical and contemporary literatures are reviewed. Volume overload and fluid congestion remain primary issues for patients with chronic heart failure. The pathophysiology is complex, and the simple concept of intravascular fluid accumulation is not adequate. The dynamics of interstitial and intravascular fluid compartment interactions and fluid redistribution from venous splanchnic beds to central pulmonary circulation need to be taken into account in strategies of volume management. Clinical bedside evaluations and right heart hemodynamic assessments can alert clinicians of changes in volume status, but only the quantitative measurement of total blood volume can help identify the heterogeneity in plasma volume and red blood cell mass that are features of volume overload in patients with chronic heart failure and help guide individualized, appropriate therapy—not all volume overload is the same.

Inferior vena cava diameter change after intravenous furosemide in patients diagnosed with acute decompensated heart failure

PURPOSE

Measurement of the inferior vena cava (IVC) diameters may improve decision-making for patients hospitalized with acute decompensated heart failure. Nevertheless, little is known about how the IVC is affected by loop diuretics. We sought to determine if bolus infusions of intravenous furosemide affect IVC diameters measured by hand-carried ultrasonography.

METHODS

We conducted a prospective cohort study at a public teaching hospital from September 2009 through June 2010. Physician investigators performed IVC ultrasonography on a convenience sample of 70 hospitalized adults who were prescribed intravenous furosemide for the diagnosis of acute decompensated heart failure.

RESULTS

Participants' median baseline IVC diameter was 2.38 cm (interquartile range, 1.91-2.55 cm). At 1-2 hours after furosemide, IVC diameters decreased an average of 0.21 cm (95% CI, 0.13-0.29 cm) and remained significantly below baseline at 2-3 hours after furosemide by an average of 0.15 cm (95% CI, 0.07-0.22 cm).

CONCLUSIONS

IVC diameters of adults diagnosed with acute decompensated heart failure become measurably smaller after single doses of intravenous furosemide. Whether this represents a true change in volume status has not been studied.

How to Improve Time to Diagnosis in Acute Heart Failure - Clinical Signs and Chest X-ray

Acute heart failure (AHF) is a leading cause of hospitalisation in developed nations with stubbornly poor outcomes in both the short and long term. Furthermore, alongside an ageing population the incidence continues to increase. Contemporary practice guidelines accordingly emphasise the importance of early recognition of heart failure in the acute setting to facilitate the timely instigation of key investigations, appropriate management and access to specialist care; all of which improve outcome. However, the diagnosis of AHF is often challenging, with no gold standard diagnostic test and presenting clinical features that may be non-specific, particularly in the elderly where they may be atypical, or masked by co-morbidity. This short review explores the main clinical signs and radiographic changes in patients with AHF relevant to clinical practice in accordance with the best available evidence.

Precision of echocardiographic estimates of right atrial pressure in patients with acute decompensated heart failure

BACKGROUND

Several methods that estimate right atrial pressure (RAP) from echocardiographic parameters have been proposed. However, their precision (i.e., how much they decrease RAP estimation uncertainty) is unknown. The aim of this prospective study was to evaluate and compare the precision of previously proposed RAP estimates in patients with acute decompensated heart failure.

METHODS

Echocardiographic and invasive hemodynamic data were acquired in 75 patients with acute decompensated heart failure. Measurements were made at the start and 48 to 72 hours after the beginning of treatment. RAP was estimated by method 1, using the cutoffs defined by inferior vena cava diameter (IVCd) and IVCd percentage change (IVCd%change) during inspiration, and by method 2, using IVCd%change and systolic to diastolic hepatic flow ratio (S/Dhep). Method 3 was used in patients with sinus rhythm, using the ratio of early tricuspid inflow and early diastolic tissue Doppler tricuspid annular velocities (E/E'ta). RAP was also estimated by resting IVCd, IVCd during inspiration, IVCd%change, right ventricular regional isovolumetric relaxation time, E/E'ta, right atrial volume index, S/Dhep, right ventricular Tei index, right ventricular E/A, and right atrial emptying fraction. Precision gain was measured as the difference between the standard deviation of RAP and the standard error of the estimate of RAP.

RESULTS

Method 1 (r = 0.48, P < .05), IVCd during inspiration (r = 0.49, P < .0001), IVCd%change (r = 0.41, P < .0001) and IVCd (r = 0.40, P < .0001) had the highest correlation with RAP. The highest gain in precision was also observed with the above methods (9%, 13%, 9%, and 8%, respectively). All other parameters had poor correlation with RAP.

CONCLUSION

In patients with advanced heart failure, echocardiographic RAP prediction methods showed only modest precision. Furthermore, none of the tested methods resulted in clinically relevant improvements of RAP estimates. Estimating RAP from a single IVCd measurement is at least as precise as using complex prediction methods.

Isolated dilatation of the inferior vena cava

The diameter and collapsibility of the inferior vena cava (IVC) should be interpreted in consideration with other clinical and echocardiographic parameters before drawing definitive diagnostic conclusions. We report a case of a 46-year-old female with isolated IVC dilation and diminished inspiratory collapse without other abnormalities, and provide a brief review of the literature.

Revisiting a classical clinical sign: jugular venous ultrasound

BACKGROUND

Increased jugular venous pressure, reflecting the increased right atrial pressure, is a classical sign of heart failure (HF) but clinical assessment may be difficult.

METHODS

In ambulatory patients with HF and control subjects, jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, during a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as diameter during Valsalva to that at rest.

RESULTS

211 patients (mean age 70 years; mean left ventricular ejection fraction 43%) and 20 controls were included. JVD (median and inter-quartile [IQR] range) at rest was 0.17 (0.15-0.20) cm in controls and 0.23 (0.17-0.33) cm in patients with HF (p=0.012), JVD ratio was 6.3 (4.3-6.8) in controls and 4.4 (2.7-5.8) in patients with HF (p=0.001).With increasing quartiles of plasma NT-proBNP, JVD at rest rose (0.20 (0.15-0.23) cm, 0.21 (0.16-0.29) cm, 0.25 (0.18-0.35) cm and 0.34 (0.20-0.53) cm (P=<0.001), whilst JVD ratio decreased (5.4 (4.2-6.4), 4.4 (3.5-6.3), 3.9 (2.4-5.4) and 2.8 (1.7-4.7); p=<0.001). JVD ratio correlated with log (NT-proBNP) (r=-0.39, p=<0.001), LV filling pressures (E/E', r=-0.33, p=<0.001) and left atrial volume (r=-0.21, p=0.002). In a multivariable regression model, only trans-tricuspid gradient and TAPSE were independently associated with JVD ratio (R(2)=0.27).

CONCLUSIONS

Distension of the JV at rest relative to the maximum diameter during a Valsalva manoeuvre (JVD ratio) identifies patients with heart failure who have higher plasma NT-proBNP levels, right ventricular dysfunction and raised pulmonary artery pressure.

IVC diameter in patients with chronic heart failure: relationships and prognostic significance

OBJECTIVES

The aim of this study was to assess the relation between inferior vena cava (IVC) diameter, clinical variables, and outcome in patients with chronic heart failure (HF).

BACKGROUND

The IVC distends as right atrial pressure rises. Therefore it might represent an index of HF severity independent of left ventricular ejection fraction (LVEF). The relation between IVC diameter and other clinical variables and its prognostic significance in patients with HF has not been explored.

METHODS

Outpatients attending a community HF service between 2008 and 2010 were enrolled. Heart failure was defined as the presence of relevant symptoms and signs and objective evidence of cardiac dysfunction: either LVEF <45% or the combination of both left atrial dilation (≥4 cm) and raised amino-terminal pro-brain natriuretic peptide (NT-proBNP) ≥400 pg/ml. Patients were followed for a median of 567 (interquartile range: 413 to 736) days. The primary composite endpoint was cardiovascular death and HF hospitalization.

RESULTS

Among the 693 patients enrolled, median age was 73 years, 33% were women, and 568 had HF. Patients with HF in the highest tertile of IVC diameter were older; had lower body mass index; were more likely to have atrial fibrillation and to be treated with diuretics; and had larger left atrial volumes, higher pulmonary pressures, and less negative values for global longitudinal strain. The LVEF and systolic blood pressure were similar across tertiles of IVC diameter. The IVC diameter and log [NT-proBNP] were correlated (r = 0.55, p < 0.001). During follow-up, 158 patients reached a primary endpoint. In a multivariable Cox regression model, including NT-proBNP, only increasing IVC diameter, urea, and the trans-tricuspid systolic gradient independently predicted a poor outcome. Neither global longitudinal strain nor LVEF were adverse predictors.

CONCLUSIONS

In patients with chronic HF with or without a reduced LVEF, increasing IVC diameter identifies patients with an adverse outcome.

Cardio-renal syndrome type 2: epidemiology, pathophysiology, and treatment

Cardiac and kidney disease are becoming increasingly more prevalent in the population, and may exist concurrently. One of the most important comorbidities in heart failure is renal dysfunction. The pathophysiology of cardio-renal syndromes is complicated, and has been divided into five categories. Cardio-Renal syndrome type 2 is described by chronic cardiac abnormalities resulting in impaired renal function. It is important to recognize this entity and to understand the pathophysiology underlying the cardiac and renal disorders to distinguish best treatment practices. The success in improved outcomes lies in optimization of heart failure therapies.

A novel expression of exercise induced pulmonary hypertension in human immunodeficiency virus patients: a pilot study

Background:

Patients with the human immunodeficiency virus (HIV) are at risk for multiple pulmonary complications including pulmonary hypertension. Exercise induced pulmonary hypertension (EIPH) has been previously described in patients with scleroderma, sickle cell disease and chronic obstructive pulmonary disease, yet has not been associated with the HIV population.

Methods:

A prospective case-control study design was implemented. Four HIV patients with unexplained dyspnea and four healthy controls underwent symptom-limited stationary bicycle exercise. Transthoracic Doppler Echocardiography was used to measure tricuspid regurgitation velocity which was used to calculate the right ventricular to right atrial pressure (RV-RA) gradient at rest and at peak exercise using the simplified Bernoulli’s equation. Change in RV-RA gradient between rest and peak exercise was calculated and considered to represent change in pulmonary arterial systolic pressure.

Results:

The mean age was 41.25 years (±8.7) for patients and 33.5 years (±6.0) for controls. The mean CD4 count of patients was 191.5 cells/μL (±136.2). Patients had a significantly higher increase in RV-RA gradient as compared to controls (180.2% vs. 27.5%, p = 0.03).

Discussion:

This pilot study suggests that it is feasible to use recumbent bicycle and transthoracic Doppler echocardiography for the evaluation of EIPH among HIV patients with dyspnea of unknown etiology. The study is too small to draw any broad conclusion. Further evaluation of this concept with a larger study is warranted.

Correlation of natriuretic peptides and inferior vena cava size in patients with congestive heart failure

BACKGROUND

The inferior vena cava (IVC) diameter and degree of inspiratory collapse are used as echocardiographic indices in the estimation of right atrial pressure. Brain-natriuretic peptides (BNPs) are established biomarkers of myocardial wall stress. There is no information available regarding the association between the IVC diameter and BNPs in patients with heart failure and various degrees of systolic performance. The purpose of this investigation is to quantify the degree to which natriuretic peptides (BNP and N-terminal pro-B natriuretic peptide [NT-ProBNP]) and echocardiographic-derived indices of right atrial pressure correlate in this patient population.

METHODS

We examined 77 patients (mean age 61 ± 17 years, 44% male) with decompensated heart failure who underwent transthoracic echocardiography and, within a timeframe of 24 hours, determination of BNP and NT-ProBNP levels in venous blood. BNP and NT-ProBNP were analyzed after log transformation. The degree of association was measured by the correlation coefficient using the Pearson's method.

RESULTS

The mean ejection fraction was 50% ± 20%, and 33% of the study cohort had a remote history of heart failure. The mean IVC diameter was 1.85 cm ± 0.5, the mean BNP was 274 pg/mL, the confidence interval (CI) was 95% (95% CI: 197-382), and the mean NT-ProBNP was 1994 pg/mL (95% CI: 1331-2989). There was a positive, albeit small, association between IVC diameter and BNP (r = 0.24, 95% CI: 0.01-0.44; P = 0.03) and NT-ProBNP (r = 0.27, 95% CI: 0.05-0.47; P = 0.01). Among patients with different degrees of IVC collapse in response to inspiration, values for BNP and NT-ProBNP did not differ substantially (P = 0.36 and 0.46 for BNP and NT-ProBNP, respectively).

CONCLUSION

Natriuretic peptides correlate weakly with IVC size and do not predict changes in response to intrathoracic pressure.

Does the physical examination still have a role in patients with suspected heart failure?

AIMS

The prognostic value of signs of congestion in patients suspected of having chronic heart failure (CHF) is unknown. Our objectives were to define their prevalence and specificity in diagnosing CHF and to determine their prognostic value in patients in a community heart failure clinic.

METHODS AND RESULTS

Analysis of referrals to a community clinic for patients with CHF symptoms. Systolic CHF (S-HF) was defined as left ventricular ejection fraction (LVEF) ≤45%, heart failure with normal ejection fraction (HeFNEF) as LVEF > 45%, and amino-terminal pro-brain natriuretic peptide >50 pmol L(-1); other subjects were defined as not having CHF. Signs of congestion were as follows: no signs; right heart congestion (RHC: oedema, jugular venous distension); left heart congestion (LHC: lung crackles); or both (R + LHC). Of 1881 patients referred, 707 did not have CHF, 853 had S-HF, and 321 had HeFNEF. The median inter-quartile range (IQR) age was 72 years (64-78), 40% were women, and LVEF was 47% (35-59). Overall, 417 patients had RHC of whom 49% had S-HF and 21% HeFNEF. Eighty-five patients had LHC of whom 43% had S-HF and 20% had HeFNEF. One hundred and seventy-two patients had R + LHC of whom 71% had S-HF and 16% had HeFNEF. During a median (IQR) follow-up of 64(44-76) months, 40% of the entire patient cohort died. The combination of R + LHC signs was an independent marker of an adverse prognosis (χ(2)-log-rank test = 186.1, P< 0.0001).

CONCLUSION

Clinical signs of congestion are independent predictors of prognosis in ambulatory patients with suspected CHF.

Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial

BACKGROUND

We determined whether estimated hemodynamics from history and physical examination (H&P) reflect invasive measurements and predict outcomes in advanced heart failure (HF). The role of the H&P in medical decision making has declined in favor of diagnostic tests, perhaps due to lack of evidence for utility.

METHODS AND RESULTS

We compared H&P estimates of filling pressures and cardiac index with invasive measurements in 194 patients in the ESCAPE trial. H&P estimates were compared with 6-month outcomes in 388 patients enrolled in ESCAPE. Measured right atrial pressure (RAP) was <8 mm Hg in 82% of patients with RAP estimated from jugular veins as <8 mm Hg, and was >12 mm Hg in 70% of patients when estimated as >12 mm Hg. From the H&P, only estimated RAP > or =12 mm Hg (odds ratio [OR] 4.6; P<0.001) and orthopnea > or =2 pillows (OR 3.6; P<0.05) were associated with pulmonary capillary wedge pressure (PCWP) > or =30 mm Hg. Estimated cardiac index did not reliably reflect measured cardiac index (P=0.09), but "cold" versus "warm" profile was associated with lower median measured cardiac index (1.75 vs. 2.0 L/min/m(2); P=0.004). In Cox regression analysis, discharge "cold" or "wet" profile conveyed a 50% increased risk of death or rehospitalization.

CONCLUSIONS

In advanced HF, the presence of orthopnea and elevated jugular venous pressure are useful to detect elevated PCWP, and a global assessment of inadequate perfusion ("cold" profile) is useful to detect reduced cardiac index. Hemodynamic profiles estimated from the discharge H&P identify patients at increased risk of early events.

Simplifying the estimation of jugular venous pressure

The classic technique of estimating jugular venous pressure, with variable inclination of the upper body and the sternal angle as the reference point, is complicated and little used in general practice. The aim of this prospective, comparative study was to assess whether estimating neck vein distension with the patient in the sitting position could be used to detecting elevated venous pressure. Patients (n = 96) who underwent right-sided cardiac catheterization or endomyocardial biopsy were evaluated. The visible height of the right internal jugular venous column above the clavicle was estimated, and the mean pressure in the right atrium or superior vena cava at cardiac catheterization was measured. Invasive venous pressure was elevated (>8 mm Hg) in 23 patients. A deep venous column visibly distended above the right clavicle in the sitting position had sensitivity of 65% and specificity of 85% to identify truly elevated venous pressure. Abdominal compression increased sensitivity to 77% but decreased specificity to 68%. In conclusion, studying the deep neck veins of a sitting patient simplifies the estimation of jugular venous pressure and has moderate to high diagnostic performance in detecting elevated central venous pressure.

Reappraisal of the Use of Inferior Vena Cava for Estimating Right Atrial Pressure

Estimation of right atrial pressure (RAP) using echocardiographic measurement of the inferior vena caval (IVC) size along with its respirophasic variation is commonly performed despite the paucity of data that critically evaluates this technique. In this study, we systematically evaluated echocardiographic imaging of the IVC for estimation of RAP in 102 patients undergoing right heart catheterization. This study established cut-off values using receiver operating characteristic analysis for 8 different IVC parameters and then prospectively tested these parameters for their ability to predict an elevated RAP. The IVC size cutoff with optimum predictive use for RAP above or below 10 mm Hg was 2.0 cm (sensitivity 73% and specificity 85%) and the optimal IVC collapsibility cutoff was 40% (sensitivity 73% and specificity 84%). Traditional classification of RAP into 5-mm Hg ranges based on IVC size and collapsibility performed poorly (43% accurate) and a new classification scheme is proposed.

A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure

Physicians' ability to accurately estimate right atrial (RA) pressure from bedside evaluation of the jugular venous waveform is poor, particularly when performed by physicians in training. Conventional ultrasound measurement of the inferior vena cava (IVC) accurately predicts RA pressure, but the cost, lack of portability, and specialized training required to acquire and interpret the data render this modality impractical for routine clinical use. The objective of this study was to compare physical examination with hand-carried ultrasound (HCU) in the detection of elevated RA pressure (>10 mm Hg). After limited training (4 hours didactic and 20 studies), 4 internal medicine residents using an HCU device estimated RA pressure from images of the IVC in 40 consecutive patients <1 hour after right-sided cardiac catheterization. RA pressure was also estimated from examination of the jugular venous pulse (JVP) in 40 patients before right-sided cardiac catheterization. RA pressure was successfully estimated from HCU images of the IVC in 90% of patients, compared with 63% from JVP examination. The sensitivity for predicting RA pressure >10 mm Hg was 82% with HCU and 14% from JVP inspection. Specificities were similar between the techniques. Overall accuracies were 71% using HCU and 60% with JVP assessment. In conclusion, internal medicine residents with brief training in echocardiography can more frequently and more accurately predict elevated RA pressure using HCU measurements of the IVC than with physical examination of the JVP.

Radial Artery Pulse Pressure Variation Correlates With Brachial Artery Peak Velocity Variation in Ventilated Subjects When Measured by Internal Medicine Residents Using Hand-Carried Ultrasound Devices

BACKGROUND

Rapid prediction of the effect of volume expansion is crucial in unstable patients receiving mechanical ventilation. Both radial artery pulse pressure variation (DeltaPP) and change of aortic blood flow peak velocity are accurate predictors but may be impractical point-of-care tools.

PURPOSES

We sought to determine whether respiratory changes in the brachial artery blood flow velocity (DeltaVpeak-BA) as measured by internal medicine residents using a hand-carried ultrasound (HCU) device could provide an accurate corollary to DeltaPP in patients receiving mechanical ventilation.

METHODS

Thirty patients passively receiving volume-control ventilation with preexisting radial artery catheters were enrolled. The brachial artery Doppler signal was recorded and analyzed by blinded internal medicine residents using a HCU device. Simultaneous radial artery pulse wave and central venous pressure recordings (when available) were analyzed by a blinded critical care physician.

RESULTS

A Doppler signal was obtained in all 30 subjects. The DeltaVpeak-BA correlated well with DeltaPP (r = 0.84) with excellent agreement (weighted kappa, 0.82) and limited intraobserver variability (2.8 +/- 2.8%) [mean +/- SD]. A DeltaVpeak-BA cutoff of 16% was highly predictive of DeltaPP > or = 13% (sensitivity, 91%; specificity, 95%). A poor correlation existed between the CVP and both DeltaVpeak-BA (r = - 0.21) and DeltaPP (r = - 0.16).

CONCLUSIONS

The HCU Doppler assessment of the DeltaVpeak-BA as performed by internal medicine residents is a rapid, noninvasive bedside correlate to DeltaPP, and a DeltaVpeak-BA cutoff of 16% may prove useful as a point-of-care tool for the prediction of volume responsiveness in patients receiving mechanical ventilation.

The Physical Examination in Heart Failure?Part II

The major components of the physical examination of patients with heart failure are presented to allow practical application by physicians and nurses working in this arena. Part II contains the key elements of the chest, precordial-cardiac, hepatic, and peripheral examination in this specific clinical setting. Supplemental maneuvers are provided. Finally, the overall role and merits of the physical examination in managing the heart failure patient are discussed.

Ultrasonography of the internal jugular vein in patients with dyspnea without jugular venous distention on physical examination

STUDY OBJECTIVE

Accurate physical examination of patients with dyspnea is important. Jugular venous distention, however, can be difficult to assess in patients. The purpose of this case series is to serve as a pilot study of how ultrasonographic examination of the internal jugular vein compares with other measures of dyspnea.

METHODS

This was a case series of 8 patients presenting with dyspnea without jugular venous distention on physical examination. Each patient underwent ultrasonographic examination of the internal jugular vein and inferior vena cava by an emergency physician sonographer blinded to all other clinical information after initial evaluation by another emergency physician for dyspnea. Results of ultrasonographic examination of the internal jugular vein and inferior vena cava were subsequently compared with initial emergency physician physical examination findings, initial chest radiography interpreted by radiologists, initial B-type natriuretic peptide levels, and final hospital discharge diagnosis.

RESULTS

Ultrasonographic examination of the internal jugular vein compared more favorably with B-type natriuretic peptide levels and chest radiographic findings than ultrasonographic examination of the inferior vena cava in these patients with dyspnea but not jugular venous distention on physical examination. It was able to identify every patient diagnosed with cardiogenic pulmonary edema on hospital discharge.

CONCLUSION

Ultrasonographic examination of the internal jugular vein appears to be helpful in patients who present with dyspnea but do not have evidence of jugular venous distention on physical examination.

Screening for left ventricular dysfunction using a hand-carried cardiac ultrasound device

BACKGROUND

The hand-carried cardiac ultrasound (HCU) device is a recently introduced imaging device, which may be potentially useful in the primary care setting.

AIM

To test the screening potential of a HCU for the detection of left ventricular (LV) dysfunction by evaluating LV ejection fraction (LVEF) and inferior vena cava (IVC) collapse. Standard echocardiographic system (SE) and plasma brain natriuretic peptide (BNP) measurements were used as a reference.

METHODS

Eighty-eight consecutive patients (56 male, aged 59+/-12 years) with suspected LV dysfunction were enrolled in the study. The HCU-LVEF was visually estimated and the SE-LVEF was derived by the Simpson's biplane method. A LVEF <40% represented LV dysfunction. An IVC collapse of <50% and BNP levels > or =15 pmol/l were considered abnormal. The correlation of HCU-LVEF, HCU-IVC and BNP to the SE-LVEF and SE-IVC was analysed independently using 2x2 tables.

RESULTS

Six patients were excluded because of poor echo images. 19/82 patients had LV dysfunction. The HCU and BNP could identify 17 and 18 out of these 19 patients, respectively. The agreement for LVEF and IVC collapse between SE and HCU was 96% for both parameters. The sensitivity of IVC collapse, HCU-LVEF and BNP in identifying patients with LV dysfunction was 26, 89 and 94%, respectively.

CONCLUSION

A HCU device can reliably be used as a screening tool for LV dysfunction.