Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension

Department of Internal Medicine, University of Arizona College of Medicine, Tucson.

OBJECTIVES. The aim of this study was to determine the sensitivity, specificity and utility of the cardiovascular examination in predicting cardiac hemodynamics in patients with advanced chronic congestive heart failure. BACKGROUND. Although the physical signs of acute left heart failure have been shown to correlate relatively well with cardiac hemodynamics, their reliability in estimating hemodynamics in patients with chronic heart failure has recently been questioned. METHODS. We prospectively recorded the history, cardiovascular physical signs present at bedside examination and the hemodynamic measurements obtained at right heart catheterization in 52 patients with chronic congestive heart failure undergoing in-hospital evaluation for possible heart transplantation. In addition, we obtained chest radiographs and multigated nuclear scans for the evaluation of left ventricular function. RESULTS. Pulmonary rales, a left ventricular third heart sound, jugular venous distension and the abdominojugular test, when positive, indicated higher right heart pressures and lower measures of cardiac performance. The presence of jugular venous distension, at rest or inducible, had the best combination of sensitivity (81%), specificity (80%) and predictive accuracy (81%) for elevation of the pulmonary capillary wedge pressure (> or = 18 mm Hg). Furthermore, in this population sample, the probability of an elevated wedge pressure was 0.86 when either variable was present. CONCLUSIONS. The bedside cardiovascular examination in the patient with chronic heart failure is extremely useful in identifying patients with elevation of right and left heart pressures. Examination for jugular venous distension at rest or by the abdominojugular test is simple and highly sensitive and specific in assessing left heart pressures in these patients.

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