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Patel S, Green A, Ashokumar S, Hoke A, Rachoin JS. Objective Methods of Assessing Fluid Status to Optimize Volume Management in Kidney Disease and Hypertension: The Importance of Ultrasound. J Clin Med 2023; 12:6368. [PMID: 37835014 PMCID: PMC10573183 DOI: 10.3390/jcm12196368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
Fluid overload, a prevalent complication in patients with renal disease and hypertension, significantly impacts patient morbidity and mortality. The daily clinical challenges that clinicians face include how to identify fluid overload early enough in the course of the disease to prevent adverse outcomes and to guide and potentially reduce the intensity of the diuresis. Traditional methods for evaluating fluid status, such as pitting edema, pulmonary crackles, or chest radiography primarily assess extracellular fluid and do not accurately reflect intravascular volume status or venous congestion. This review explores the rationale, mechanism, and evidence behind more recent methods used to assess volume status, namely, lung ultrasound, inferior vena cava (IVC) ultrasound, venous excess ultrasound score, and basic and advanced cardiac echocardiographic techniques. These methods offer a more accurate and objective assessment of fluid status, providing real-time, non-invasive measures of intravascular volume and venous congestion. The methods we discuss are primarily used in inpatient settings, but, given the increased pervasiveness of ultrasound technology, some could soon expand to the outpatient setting.
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Affiliation(s)
- Sharad Patel
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Adam Green
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Sandhya Ashokumar
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
| | - Andrew Hoke
- Department of Medicine, Cooper University Health Care, Camden, NJ 08103, USA;
| | - Jean-Sebastien Rachoin
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
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Simonavičius J, Sanders van-Wijk S, Rickenbacher P, Maeder MT, Pfister O, Kaufmann BA, Pfisterer M, Čelutkienė J, Puronaitė R, Knackstedt C, van Empel V, Brunner-La Rocca HP. Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial. Am J Med 2019; 132:e679-e692. [PMID: 31051151 DOI: 10.1016/j.amjmed.2019.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between longitudinal clinical congestion pattern and heart failure outcome is uncertain. This study was designed to assess the prevalence of congestion over time and to investigate its impact on outcome in chronic heart failure. METHODS A total of 588 patients with chronic heart failure older than 60 years of age with New York Heart Association (NYHA) functional class ≥II from the TIME-CHF study were included. The endpoints for this study were survival and hospitalization-free heart failure survival. Orthopnea, NYHA ≥III, paroxysmal nocturnal dyspnea, hepatomegaly, peripheral pitting edema, jugular venous distension, and rales were repeatedly investigated and related to outcomes. These congestion-related signs and symptoms were used to design a 7-item Clinical Congestion Index. RESULTS Sixty-one percent of patients had a Clinical Congestion Index ≥3 at baseline, which decreased to 18% at month 18. During the median [interquartile range] follow-up of 27.2 [14.3-39.8] months, 17%, 27%, and 47% of patients with baseline Clinical Congestion Index of 0, 1-2, and ≥3 at inclusion, respectively, died (P <.001). Clinical Congestion Index was identified as an independent predictor of mortality at all visits (P <.05) except month 6 and reduced hospitalization-free heart failure survival (P <.05). Successful decongestion was related to better outcome as compared to persistent congestion or partial decongestion (log-rank P <0.001). CONCLUSIONS The extent of congestion as assessed by means of clinical signs and symptoms decreased over time with intensified treatment, but it remained present or relapsed in a substantial number of patients with heart failure and was associated with poor outcome. This highlights the importance of appropriate decongestion in chronic heart failure.
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Affiliation(s)
- Justas Simonavičius
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | | | - Peter Rickenbacher
- Department of Cardiology, University Hospital Bruderholz, Bruderholz, Switzerland
| | - Micha T Maeder
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Otmar Pfister
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Jelena Čelutkienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Roma Puronaitė
- Department of Information Systems, Centre of Informatics and Development, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Clinic of Cardiac and Vascular diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; Institute of Data Science and Digital Technologies, Faculty of Mathematics and Informatics, Vilnius University, Vilnius, Lithuania
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Cardiology, University Hospital Basel, Basel, Switzerland
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Validity of direct ophthalmoscopy skill evaluation with ocular fundus examination simulators. Can J Ophthalmol 2014; 49:377-81. [DOI: 10.1016/j.jcjo.2014.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 05/09/2014] [Accepted: 06/16/2014] [Indexed: 11/21/2022]
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Caldentey G, Khairy P, Roy D, Leduc H, Talajic M, Racine N, White M, O'Meara E, Guertin MC, Rouleau JL, Ducharme A. Prognostic Value of the Physical Examination in Patients With Heart Failure and Atrial Fibrillation. JACC-HEART FAILURE 2014; 2:15-23. [DOI: 10.1016/j.jchf.2013.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 10/01/2013] [Accepted: 10/03/2013] [Indexed: 11/28/2022]
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Michaels AD, Khan FU, Moyers B. Experienced clinicians improve detection of third and fourth heart sounds by viewing acoustic cardiography. Clin Cardiol 2011; 33:E36-42. [PMID: 20127893 DOI: 10.1002/clc.20586] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical assessment of diastolic heart sounds is challenging. HYPOTHESIS We sought to examine whether visual inspection of acoustic cardiographic tracings augments the accuracy of medical students' and physicians' detection of third and fourth heart sounds (S(3), S(4)) compared to auscultation alone. METHODS A total of 90 adults referred for left heart catheterization underwent digital precordial heart sound recordings by computerized acoustic cardiography. Two blinded, experienced readers using a consensus method determined the presence of the S(3)/S(4) on each file. There were 35 subjects from the following 5 groups participating in this study from 1 teaching institution: first-year medical students (n = 5), fourth-year medical students (n = 5), interns (n = 5), medicine residents (n = 5), cardiology fellows (n = 5), and attendings (n = 10). Using a computer module, each subject listened to the heart sounds alone and documented whether an S(3)/S(4) was present. Next, subjects listened to each recording in random order while viewing phonocardiographic tracings, and recorded S(3)/S(4) presence. RESULTS An S(3) was present in 21 patients (23%) and an S(4) in 31 patients (34%) by consensus overread in 90 recordings. Baseline accuracy for auscultation of S(3)/S(4) did not change with level of experience. While viewing the acoustic cardiogram, first-year medical students had minimal improvement in S(3) (2%) and S(4) (11%) accuracy. More experienced subjects improved S(3) accuracy by 8% to 18% and S(4) by 15% to 32% (P < .05). Accuracy was superior for S(3) compared to S(4) in all ausculatory groups. CONCLUSIONS While listening to heart sound recordings, viewing acoustic cardiography increased subjects' accuracy in detecting diastolic heart sounds, particularly among more experienced subjects. There was greater improvement for S(4) compared to S(3) detection.
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Affiliation(s)
- Andrew D Michaels
- Division of Cardiology, Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132-2401, USA.
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Gupta S, Michaels AD. Relationship between accurate auscultation of the fourth heart sound and the level of physician experience. Clin Cardiol 2009; 32:69-75. [PMID: 19215005 DOI: 10.1002/clc.20431] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Poor performance by physicians-in-training and interobserver variability between physicians has diminished clinicians' confidence in the value of the fourth heart sound (S4). HYPOTHESIS We sought to determine if accurate auscultation of an S4 improves with advancing levels of experience. METHODS We performed a prospective study of 100 patients undergoing left heart catheterization. Patients underwent blinded auscultation by 4 physicians (each from 1 of 4 different levels of experience), computerized acoustic cardiography, measurement of B-type natriuretic peptide (BNP) levels, echocardiography for measurement of left ventricular ejection fraction (LVEF), and cardiac catheterization for measurement of left ventricular end-diastolic pressure (LVEDP). RESULTS While cardiology fellows', residents', and interns' auscultatory findings demonstrated no significant agreement with acoustic cardiography, an S4 auscultated by cardiology attendings had moderate diagnostic accuracy with acoustic cardiography (odds ratio [OR]: 2.31; receiver-operating-characteristic [ROC] area: 0.60). The sensitivities of the S4 were low (39%-46%) for identifying patients with abnormal measures of left ventricular filling pressure (BNP and LVEDP, respectively), and the specificities were fair (76%-80%) with acoustic cardiography. The S4 was not associated with abnormal LVEF. None of the ausculatory groups performed as well as acoustic cardiography in separating patients based on objective measures of left ventricular filling pressure. Acoustic cardiography had the lowest (superior) negative likelihood ratios compared to any ausculatory group. CONCLUSIONS The S4 auscultated by cardiology attendings demonstrated superior diagnostic test characteristics compared with internal medicine housestaff and cardiology fellows. Correlations between the S4 and measures of ventricular filling pressure were superior for acoustic cardiography compared to the auscultator groups.
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Affiliation(s)
- Saurabh Gupta
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah 84132-2401, USA
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Drazner MH, Rame JE, Dries DL. Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction. Am J Med 2003; 114:431-7. [PMID: 12727575 DOI: 10.1016/s0002-9343(03)00058-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the independent prognostic value of a third heart sound (S(3)) and elevated jugular venous pressure in patients with asymptomatic left ventricular dysfunction. METHODS We performed a post hoc analysis of 4102 participants from the Studies of Left Ventricular Dysfunction (SOLVD) prevention trial. In that trial, participants with asymptomatic or minimally symptomatic left ventricular dysfunction (New York Association class I or II, left ventricular ejection fraction < or =0.35, no treatment for heart failure) were allocated randomly to enalapril or placebo and followed for a mean (+/- SD) of 34 +/- 14 months. The presence of an S(3) and elevated jugular venous pressure was ascertained by physical examination at study enrollment. We used multivariate proportional hazards models to determine whether these physical examination findings were associated with the development of heart failure, a prespecified endpoint of the SOLVD prevention trial. RESULTS At baseline, 209 subjects (5.1%) had an S(3) and 70 (1.7%) had elevated jugular venous pressure. Heart failure developed in 1044 subjects (25.5%). After adjusting for other markers of disease severity, an S(3) was associated with an increased risk of heart failure (relative risk [RR] = 1.38; 95% confidence interval [CI]: 1.09 to 1.73; P = 0.007) and the composite endpoint of death or development of heart failure (RR = 1.34; 95% CI: 1.09 to 1.64; P = 0.005). Elevated jugular venous pressure was also associated with these outcomes in multivariate models. CONCLUSION The physical examination provides prognostic information among patients with asymptomatic or minimally symptomatic left ventricular dysfunction.
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Affiliation(s)
- Mark H Drazner
- Heart Failure Research Unit, Donald W. Reynolds Cardiovascular Clinical Research Center, Dallas, Texas 75390, USA.
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Stern DT, Mangrulkar RS, Gruppen LD, Lang AL, Grum CM, Judge RD. Using a multimedia tool to improve cardiac auscultation knowledge and skills. J Gen Intern Med 2001; 16:763-9. [PMID: 11722691 PMCID: PMC1495295 DOI: 10.1111/j.1525-1497.2001.10347.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Today's medical school graduates have significant deficits in physical examination skills. Medical educators have been searching for methods to effectively teach and maintain these skills in students. The objective of this study was to determine if an auscultation curriculum centered on a portable multimedia CD-ROM was effective in producing and maintaining significant gains in cardiac auscultatory skills. DESIGN Controlled cohort study. PARTICIPANTS All 168 third-year medical students at 1 medical school in an academic medical center. INTERVENTIONS Students were tested before and after exposure to 1 or more elements of the auscultation curriculum: teaching on ward/clinic rotations, CD-ROM comprehensive cases with follow-up seminars, and a CD-ROM 20-case miniseries. The primary outcome measures were student performance on a 10-item test of auscultation skill (listening and identifying heart sound characteristics) and a 30-item test of auscultation knowledge (factual questions about auscultation). A subset of students was tested for attenuation effects 9 or 12 months after the intervention. RESULTS Compared with the control group (1 month clinical rotation alone), students who were also exposed to the CD-ROM 20-case miniseries had significant improvements in auscultation skills scores (P < .05), but not knowledge. Additional months of clerkship, comprehensive CD-ROM cases, and follow-up seminars increased auscultation knowledge beyond the miniseries alone (P < .05), but did not further improve auscultation skills. Students' auscultation knowledge diminished one year after the intervention, but auscultation skills did not. CONCLUSION In addition to the standard curriculum of ward and conference teaching, portable multimedia tools may help improve quality of physical examination skills.
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Affiliation(s)
- D T Stern
- Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Mich., USA.
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Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001; 345:574-81. [PMID: 11529211 DOI: 10.1056/nejmoa010641] [Citation(s) in RCA: 482] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The independent prognostic value of elevated jugular venous pressure or a third heart sound in patients with heart failure is not well established. METHODS We performed a retrospective analysis of the Studies of Left Ventricular Dysfunction treatment trial, in which 2569 patients with symptomatic heart failure or a history of it were randomly assigned to receive enalapril or placebo. The mean (+/-SD) follow-up was 32+/-15 months. The presence of elevated jugular venous pressure or a third heart sound was ascertained by physical examination on entry into the trial. The risks of hospitalization for heart failure and progression of heart failure as defined by death from pump failure and the composite end point of death or hospitalization for heart failure were compared in patients with these findings on physical examination and patients without these findings. RESULTS Data on 2479 patients were complete and analyzed. In multivariate analyses that were adjusted for other markers of the severity of heart failure, elevated jugular venous pressure was associated with an increased risk of hospitalization for heart failure (relative risk, 1.32; 95 percent confidence interval, 1.08 to 1.62; P<0.01), death or hospitalization for heart failure (relative risk, 1.30; 95 percent confidence interval, 1.11 to 1.53; P<0.005), and death from pump failure (relative risk, 1.37; 95 percent confidence interval, 1.07 to 1.75; P<0.05). The presence of a third heart sound was associated with similarly increased risks of these outcomes. CONCLUSIONS In patients with heart failure, elevated jugular venous pressure and a third heart sound are each independently associated with adverse outcomes, including progression of heart failure. Clinical assessment for these findings is currently feasible and clinically meaningful.
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Affiliation(s)
- M H Drazner
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75390-9034, USA.
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Lok CE, Morgan CD, Ranganathan N. The accuracy and interobserver agreement in detecting the 'gallop sounds' by cardiac auscultation. Chest 1998; 114:1283-8. [PMID: 9824002 DOI: 10.1378/chest.114.5.1283] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To determine the observer accuracy and interobserver agreement in identifying S4 and S3 by cardiac auscultation and whether they improve with increasing observer experience. DESIGN Prospective, blinded study. SETTING Cardiology and general internal medicine wards in a university-affiliated teaching hospital. PATIENTS Forty patients with a cardiac diagnosis and 6 patients without were studied. MEASUREMENTS AND RESULTS Two cardiologists, one general internist, three senior and two junior postgraduate internal medicine trainees, blinded to the patients' characteristics, examined the patients and documented their findings on a questionnaire. Computerized phonocardiogram was obtained in all patients as a gold standard and was interpreted by a blinded, independent cardiologist. The mean positive predictive values for S4 and S3 were 51% (range, 24 to 100%) and 71% (range, 50 to 88%), respectively. The mean negative predictive values for S4 and S3 were 82% (range, 67 to 94%) and 64% (range, 56 to 85%), respectively. The overall interobserver agreements for detecting S4 was K = 0.05 (95% confidence interval [CI], 0.01 to 0.09) and S3 was K = 0.18 (95% CI, 0.13 to 0.24). There was no apparent trend in the accuracy or interobserver agreement with regard to the level of observer experience. CONCLUSION The agreement between observers and the phonocardiographic gold standard in the correct identification of S4 and S3 was poor and the lack of agreement did not appear to be a function of the experience of the observers. The overall interobserver agreement for the detection of either S4 or S3 was little better than chance alone.
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Affiliation(s)
- C E Lok
- Department of Medicine, Sunnybrook Health Science Centre, the University of Toronto, Ontario, Canada.
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Jones JS, Hunt SJ, Carlson SA, Seamon JP. Assessing Bedside Cardiologic Examination Skills Using “Harvey,” a Cardiology Patient Simulator. Acad Emerg Med 1997. [DOI: 10.1111/j.1553-2712.1997.tb03664.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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