The Physical Examination in Heart Failure?Part II

Impact of signs and symptoms on the prognosis of patients with HFmrEF

BACKGROUND

Worsening of heart failure (HF) symptoms is the leading cause of medical contact and hospitalization of patients with mildly reduced ejection fraction (HFmrEF). The prognostic value of signs and symptoms for patients with HFmrEF is currently unclear. This study investigated the prognostic impact of signs and symptoms in HFmrEF patients.

METHODS

A Cox proportional risk regression model analyzed the relationship between the number of signs/symptoms and outcomes in 1691 hospitalized HFmrEF patients. Ten significant signs and symptoms were included. Patients were divided into three groups (A: ≤2, B: 3-5, C: ≥6 signs/symptoms). Stratified analysis on male and female patients was performed. The primary endpoint was all-cause mortality, and the secondary outcome was a composite of cardiovascular death and heart failure readmission (CV events) post-discharge.

RESULTS

After a median follow-up of 33 months, all-cause mortality occurred in 457 patients and CV events occurred in 977 patients. Incidence of all-cause mortality was 20.7%, 32.3%* and 49.4%*† in group A, B and C of male patients, (*P < 0.05 vs. A, †P < 0.05 vs. B) and 18.8%, 33.6% and 55.8%* in group A, B and C of female patients. Incidence of CV events was 64.8%, 70.1%* and 87.5%* in group A, B and C of male patients, 61.9%, 75.3%, and 86.1%* in group A, B and C of female patients. Multivariate Cox regression showed older age, renal insufficiency, higher number of signs and symptoms (≥ 3, hazard ratio [HR] 1.317, 95% confidence interval [CI] 1.070-1.621, P = 0.009; ≥6, HR 1.982, 95% CI 1.402-2.801, P < 0.001), myocardial infarction, stroke, faster heart rate on admission, and diabetes were independently associated with all-cause mortality(all P < 0.05). Similarly, higher number of signs and symptoms (≥ 3, HR 1.271, 95% CI 1.119-1.443, P < 0.001; ≥6, HR 1.955, 95% CI 1.524-2.508, P < 0.001), older age, renal insufficiency, atrial fibrillation, and diabetes were independently associated with cardiovascular events (all P < 0.05).

CONCLUSIONS

Higher number of symptoms and signs is associated with increased risk of all-cause mortality and CV events in HFmrEF patients. Our results highlight the prognostic importance of careful inquiry on HF symptoms and related physical examination in HFmrEF patients.

Congestive Heart Failure

Heart disease is the leading cause of death in the United States with an estimated 6 million adults living with heart failure. In patients with heart failure, the physical examination can provide important prognostic information and is also used to guide both diagnosis and management, including determining the need for inpatient versus outpatient management. Presenting symptoms include dyspnea, peripheral edema, orthopnea, paroxysmal nocturnal dyspnea, and bendopnea. In patients with suspected heart failure, a "head-to-toe" physical examination approach is recommended with the addition of special maneuvers such as the measurement of jugular venous pressure, valsalva maneuver, and hepatojugular reflux as needed.

Using smart speakers to contactlessly monitor heart rhythms

Heart rhythm assessment is indispensable in diagnosis and management of many cardiac conditions and to study heart rate variability in healthy individuals. We present a proof-of-concept system for acquiring individual heart beats using smart speakers in a fully contact-free manner. Our algorithms transform the smart speaker into a short-range active sonar system and measure heart rate and inter-beat intervals (R-R intervals) for both regular and irregular rhythms. The smart speaker emits inaudible 18–22 kHz sound and receives echoes reflected from the human body that encode sub-mm displacements due to heart beats. We conducted a clinical study with both healthy participants and hospitalized cardiac patients with diverse structural and arrhythmic cardiac abnormalities including atrial fibrillation, flutter and congestive heart failure. Compared to electrocardiogram (ECG) data, our system computed R-R intervals for healthy participants with a median error of 28 ms over 12,280 heart beats and a correlation coefficient of 0.929. For hospitalized cardiac patients, the median error was 30 ms over 5639 heart beats with a correlation coefficient of 0.901. The increasing adoption of smart speakers in hospitals and homes may provide a means to realize the potential of our non-contact cardiac rhythm monitoring system for monitoring of contagious or quarantined patients, skin sensitive patients and in telemedicine settings.

Anran Wang et al. present a contact-free method of monitoring individual heart beats by converting smart-speakers into active sonar systems. Their approach is capable of measuring heart rhythms with high accuracy in both healthy participants and hospitalized patients, and may be a useful healthcare tool for remote diagnosis or patient monitoring.

Clinical and Prognostic Significance of Positive Hepatojugular Reflux on Discharge in Acute Heart Failure: Insights from the ESCAPE Trial

Background. There has been a decline in emphasis of the value of physical examination in heart failure (HF) with increased reliance on cardiac imaging. We aim to study the clinical and prognostic significance of positive hepatojugular reflux (HJR) on discharge in patients hospitalized with HF. Methods. Using the ESCAPE trial data, patients were compared according to the presence or absence of a positive HJR on discharge. The primary study endpoints were all-cause mortality and a composite endpoint of death, rehospitalization, and cardiac transplant during the first 6 months after discharge. Results. Among 392 patients (age: 56 years, 74% men), the HJR correlated well with clinical and objective hemodynamic markers of volume overload including right atrial pressure (RAP, P = 0.002), pulmonary capillary wedge pressure (PCWP, P = 0.006), and inferior vena cava size during inspiration (P = 0.005) and expiration (P = 0.003). The RAP had the highest AUC for predicting a positive HJR on admission (AUC: 0.655, P = 0.004) and discharge (AUC: 0.672, P = 0.001). Cox's proportional hazards analysis revealed that a positive HJR on discharge is an independent predictor of 6-month mortality (estimated hazard ratio: 1.689; 95% CI: 1.032–2.764; P = 0.037) after adjusting for age, baseline creatinine, baseline hematocrit, baseline NYHA class, chronic obstructive pulmonary disease, and the presence of tricuspid regurgitation. Conclusion. The HJR should be routinely checked in patients admitted with acute HF throughout hospitalization and especially on discharge as it serves as an important prognostic marker for postdischarge outcomes.

Clinical significance of bilateral leg edema and added value of monitoring weight gain during follow-up of patients with established heart failure

PURPOSE

This study evaluated the clinical characteristics of bilateral leg edema during follow-up of heart failure (HF) patients and determined the added value of monitoring fluid weight gain for deciding whether this non-specific sign is a more clinically relevant sign.

METHODS

Retrospective analysis was performed on 1826 visits from 83 ambulatory patients with established mild-to-moderate HF. Evaluated HF-related signs included leg edema, pulmonary crackles, S3, weight gain, and ultrasound pleural effusion.

RESULTS

During follow-up, 75 patients with 161 visits had at least one of the following HF-related events: weight gain (n = 107), leg edema (n = 90), ultrasound pleural effusion (n = 85), pulmonary crackles (n = 29), and S3 (n = 16). Compared with the events of sole leg edema (n = 23), leg edema events with additional HF-related sign(s) (n = 67) accompanied more symptomatic worsening (7% vs. 55%, P < 0.0001), and a higher incidence (61% vs. 96%, P = 0.0002) and magnitude of increased serum B-type natriuretic peptide. Sole leg edema events rarely progressed to worsening HF before the next regular clinic visit. Patients with the event of both leg edema and weight gain more often experienced worsening HF requiring extra clinic visits and/or hospitalization. Amongst a total of 67 leg edema events with additional HF-related signs, 56 (84%) coexisted with weight gain. Therefore, additional monitoring of weight gain efficiently distinguished the clinically significant leg edema events from insignificant sole leg edema events.

CONCLUSIONS

During follow-up of mild-to-moderate HF patients, sole leg edema appeared around 30% of the leg edema events, which is considered clinically insignificant. Additional checking for weight gain could be useful for determining whether this sign is a clinically relevant HF-related sign. The appearance of these both signs during follow-up of established HF patients should be intentionally watched or treated by extra diuretics and/or drug adjustment to prevent worsening of HF.

Clinical characteristics of lower-extremity edema in stage A cardiovascular disease status defined by the ACC/AHA 2001 Chronic Heart Failure Guidelines

BACKGROUND

Checking for lower-extremity edema is important for diagnosing, monitoring, and managing heart failure (HF). However, the characteristics of this sign in the early stages of cardiovascular disease (stage A, as defined by the American College of Cardiology/American Heart Association 2001 chronic HF guidelines) have not been adequately explored.

HYPOTHESIS

We hypothesized that stage A HF patients (at risk for HF) are free from leg edema.

METHODS

After the exclusion of patients with high serum creatinine levels (≥1.2 mg/dL), abnormal electrocardiogram rhythm, and/or comorbid critical disease(s), we studied the prevalence and predictors for leg edema in 274 subjects at risk for heart failure but without structural heart disease or symptoms of HF.

RESULTS

The overall prevalence of lower-extremity edema was 33 of 274 patients (12.0%; 95% confidence interval: 8.2%-15.9%). In most patients (29/33, 88%), the leg edema involved only the ankle and foot. Compared with patients without leg edema (n = 241), those with leg edema (n = 33) were older (age, 74 ± 11 7 vs 69 ± 12 years, P = 0.006), more likely to present with pulmonary crackles (52% vs 31%, P < 0.03), and more likely to have varicose veins (55% vs 15%, P < 0.001). Leg edema and varicose veins coexisted in 19 (58%) patients, of whom 16 patients were women. On multivariate analysis, the presence of varicose veins was the only independent predictor of the appearance of bilateral leg edema (odds ratio: 8.18, 95% confidence interval: 3.92-17.1, P < 0.001).

CONCLUSIONS

A mild degree of leg edema is not uncommon in patients at risk for HF. Recognition of this phenomenon might be important for evaluation, monitoring, and self-care of HF patients.

Bedside assessment of cardiac hemodynamics: the impact of noninvasive testing and examiner experience

BACKGROUND

Knowledge of cardiac filling pressures is critical in the diagnosis and management of patients with dyspnea or heart failure. Echocardiography and B-natriuretic peptide (BNP) testing are commonly used to estimate these pressures, but their incremental value beyond physical examination remains unknown.

METHODS

Right and left heart filling pressures were prospectively estimated as "normal" or "abnormal" by staff cardiologists and cardiovascular trainees based upon physical examination findings alone, or examination coupled with echocardiographic and BNP data in patients referred for cardiac catheterization. Net reclassification improvement was calculated to determine whether echocardiographic/BNP data had incremental value in the determination of right and left heart pressures.

RESULTS

Two hundred fifteen observations were made by 9 examiners in 116 consecutive patients. Right and left heart pressures were accurately predicted from examination alone in 71% and 60% of observations, respectively. Examination-based accuracy was greater for staff cardiologists compared with trainees for right heart (82 vs 67%, P=.03) and left heart pressures (71% vs 55%, P=.03). Exposure to echocardiographic and BNP data did not enhance accuracy beyond bedside examination alone, both for left heart pressures (net reclassification improvement=-0.004; 95% confidence interval, -0.12-0.12) and right heart pressures (net reclassification improvement=0.02, 95% confidence interval, -0.09-0.13).

CONCLUSIONS

Cardiac filling pressures can be estimated from physical examination with modest accuracy, which is enhanced with experience. While echocardiographic and BNP data predict cardiac filling pressures, they may not provide information of incremental value beyond examination alone. Rigorous teaching and practice of cardiac examination skills should continue to be emphasized during medical training.

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.