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Heart Failure: Bob Badgett, MD, discusses the clinical examination for heart failure.
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Heart Failure: Bob Badgett, MD, discusses the clinical examination for heart failure.
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News & Perspectives section. Today, I have the pleasure of speaking with Dr. Bob Badgett about heart failure. Dr. Badgett, why don't you introduce yourself to our listeners? >> Thank you. So my name is Bob Badgett and I'm in the Division of Hospital Medicine at the University of Texas Health Science Center in San Antonio. >> Dr. Badgett, what are the reference standard tests for heart failure? >> Well, right at the beginning, we start with the most difficult question. I think it's best to go back to what Braunwald says about his definition, which is, "Heart failure is a pathophysiological state which abnormality of cardiac function is responsible for failure of the heart to pump blood at a rate commensurate with the requirements of the metabolising tissues, or it will only do so with a filling pressure that's elevated." The problem with this definition is it's very hard to measure in clinical practice.
And we also have to remember that there's two different underlying pathophysiologies. Is it systolic heart failure or diastolic heart failure? So to try to implement this definition, a very good option for the reference test is a high left ventricular end diastolic pressure or LVEDP in the absence of a noncardiac reason for a high LVEDP. But then it gets a little more complicated. The LVEDP is a nice measure acutely during heart failure because it's fairly reliable that it's going to be elevated and it's abnormal both in systolic and diastolic dysfunction.
The problem with it is the LVEDP and most every other measure for heart failure is normal after treatment when the patient is asymptomatic. So for that setting, we now turn to the echocardiography. And as we all know it's a good test for measuring systolic dysfunction by looking at the ejection fraction, but the ability to measure diastolic dysfunction is uncertain and still improving. The most recent studies suggest that it may be as good as 80% sensitive for detecting diastolic dysfunction, but these aren't widely replicated studies.
So the next step is to define diastolic dysfunction then and the cause of difficulties with the echo. And you may make a good definition is high LVEDP, either now or in the past, but with a measured normal ejection fraction. So those are the definitions I would propose. Looking at the LVEDP and then dividing up the patients by what is their ejection fraction. Keep an eye out for improving measures of diastolic dysfunction by echo.
At this point, I should note that JAMA has two reviews of heart failure. The one we're discussing today compares a clinical exam to one of these objective measures of heart failure. The other review compares a clinical examination to expert determination of heart failure after comprehensive heart review. And there's pros and cons of these different definitions. >> Dr. Badgett, what do we know about the prevalence of heart failure and are there important demographic characteristics? >> Well, it's becoming more prevalent and more prevalent in situations where you have risk factors such as ischemic heart disease, hypertension.
Regarding the demographic characteristics, the things that are important to remember is that older and obese patients are a little bit more likely to have diastolic dysfunction. Then another important fact is that race, specifically African Americans, knowing that may not help you determine if they have heart failure, but it may help you decide how to treat them because African Americans are more likely to have polymorphisms of the G protein-coupled cell surface receptor kinase, so they may more likely need nitrates and hydralazine, still an evolving area of research.
And the other important thing, somewhat about demographics, is once a patient is known to have systolic dysfunction, your interpretation of their findings should change in two ways. First, they now have a higher prevalence of congestion and so you should ramp up your assessment of congestion whenever you see them. And second, any clinical findings that are based on cardiomegaly, such as a point -- a maximal endpoint, the PMI on the physical exam or the chest x-ray, looking at cardiomegaly now have to be seen differently because they're persistent findings and it won't come and go with treatment of heart failure.
>> Which symptoms, when present, increase the probability of a diagnosis of heart failure? >> Well, from our review of the studies, only two findings, dyspnea and orthopnea, are consistently, independently predictive findings of heart failure. >> Which history and physical examination findings are helpful when detecting heart failure, and which findings are not as helpful? >> Let's divide this question into which type of heart failure we're discussing. So let's first look at, simply, is their filling pressure increased?
In the findings that are most consistently helpful, first a radiographic finding, which is do they have redistribution on the chest x-ray? Then a physical finding, do they have jugular venous distention? Now in the somewhat helpful findings, these are ones that are shown in many but not all studies to be helpful, are dyspnea and orthopnea like we already mentioned, but then, in addition, tachycardia, low blood pressure, low proportional pulse pressure, S3, rales, abdominal jugular reflux.
And now going back to the radiograph, cardiomegaly. And then the last finding that's worth mentioning for increased filling pressure is edema, a tricky finding, not helpful when absent, but may be helpful when present. Now the second question is if you decide to have abnormal filling pressure or separately, you're just thinking about ejection fraction, trying to determine who has abnormal ejection fraction, the very helpful findings are radiographic cardiomegaly or redistribution.
Going to the EKG is anterior Q-waves or left bundle branch block. Now going to the physical exam, abnormal apical impulse and, again, pretty much the same abnormal vital signs, tachycardia, low blood pressure, low proportional pulse pressure. And then the other findings, S3, rales, dyspnea, history of infarction, and then jugular venous distention and edema as before. Pretty similar findings compared to increased filling pressure because there's a strong correlation with your filling pressure and your ejection fraction, but not quite the same findings.
>> How can you distinguish diastolic from systolic dysfunction? >> This becomes the third type, or definition of heart failure to think about. So which ones have diastolic dysfunction? The best finding for this is if during the episode of heart failure, the patient has an elevated blood pressure at the bedside. So recall that, in systolic dysfunction, they're more likely to have a low blood pressure. Now the patient is more likely to have an elevated blood pressure.
>> Would you tell us how to incorporate the information from the BNP essay with the findings on the clinical examination? >> Well, the BNP is a new tool that's come out since we first did our review. So I've had to think about how to use it, incorporating it with other findings. So because there are not very good multivariate studies of using the BNP with many of the other findings, looking at one of these objective reference standard measures of heart failure, I think the best way to do this is with a [inaudible] analysis.
So if you go to the BNP studies, it looks like the BNP is much more sensitive than specific. So sensitivity is at least 90%, very nice. Specificity is mediocre, around 70%. So using the nomenclature for diagnostic tests, we would call this a "SnNOut." And to remind you, SnNOut has two ns, an intentional misspelling, meaning findings that are highly sensitive, when negative help rule out.
So the BNP, when negative, helps rule out. When positive, it kind of depends on just how elevated it is. So if you construct the two-by-two table using that sensitivity and specificity, you can see that a BNP is negative -- if negative, is helpful as long as the pretest probability of heart failure is less than 25%. So, therefore, I combine it with my other findings in the following way. When my findings make me think that, overall, the chance of heart failure is less than half, or I should actually say less than 25% or so, I think the BNP is helpful because then, if it's normal, less than 50 or maybe less than 100, I feel fairly certain that the patient doesn't have heart failure.
So it's best in low prevalent situations at ruling out heart failure. >> Is there anything else new since your review that JAMAevidence users should know about heart failure in relation to the physical examination? >> Well, several new things have come out, and they can be some interesting topics to keep an eye out for. First, because we're having better measures of diastolic dysfunction, so now we can use the echo as a better reference standard in our studies, it's starting to look like the fourth heart sound which, in the past I've always thought to be a boring finding in the setting of heart failure, it may turn out to have some role as a correlate with diastolic dysfunction.
But it's hard to say anything certain as the research is still emerging on that. But it looks like it may correlate with diastolic dysfunction until the diastolic dysfunction gets severe, at which time the fourth heart sound may lose its ability. The second emerging topic that's come out is hemodynamic profiling heart failure patients into different groups that may benefit from different treatments. And this all hinges on the idea that the heart failure patient who is also having hypoperfusion by physical exam may need specific treatments such as reducing some of their medications, beta blockers and ACE inhibitors, temporarily while you improve their fluid state, and then restarting these medicines later.
So this hinges, then, on how good is the physical findings at detecting hypoperfusion? And, unfortunately, I don't think they've been studied as well as other findings for heart failure. Four findings are proposed The proportional pulse pressure less than 25%, delayed capillary refilling, [inaudible] modeling and [inaudible] temperature. And I think I can safely say, in isolation, none of these findings are great, but unfortunately, they haven't been well studied in a combination.
So looking out for that. And the other thing to look out for is that there may be easy, non-invasive measures of hypoperfusion such as the oxygen saturation of the thenar eminence or by using a blood test of the lactate clearance. Then the treatment part of this question still needs more examination. So how well do these different profiles need different treatments? Then the last topic to keep an eye out for is using the physical examination not as a diagnostic test, but as a target measure for treating heart failure.
And now that the BNP is available, there's a lot of tests coming out on using the BNP as a target for your treating heart failure, so you treat to a certain BNP. Now not the thrust of these studies, but to me a very interesting side feature of the studies is that they're usually comparing targeting the BNP to targeting the physical exam. And so the better done studies standardize a physical exam with the Framingham score for heart failure, and the studies aren't perfectly clear yet but they suggest as you do an objective evaluation of heart failure with the Framingham score, you might be able to target your heart failure treatment just as well as using the BNP.
Interestingly, the Framingham scores they look at allow you to have a score of 2 or less, which means you can have one finding of heart failure and, if the patient is otherwise asymptomatic, it doesn't mean you have to continue treating them. I think it's an interesting area to keep looking for. And so those are the three areas that may change over the next few years. >> Dr. Badgett, are there any key points about heart failure that you'd like to emphasize to our listeners? >> So the first summary conclusion that, even when we're very careful about how we interpret our findings, which findings we select to use in our assessment, that our summary measures for heart failure are not that great.
Our likelihood ratio of positive, when we pooled our favorite studies, was 4.5. Our negative likelihood ratio was 0.45. So while there's some ability for the clinical evaluation, it's not that strong that, by itself, it can say yes or no heart failure. So, first, you should have a very low threshold to add the electrocardiogram and the chest x-ray to your evaluation of someone with heart failure. Second, even with that, if you're in a setting where the prevalence of heart failure is enriched, such as someone with a recent or anytime history of myocardial infarction or someone who you're trying to evaluate their fluid status and they already have known systolic dysfunction, you need to recognize the increased prevalence of heart failure and, in these settings, you may have to get a further test.
So the patient after infarction, you're probably going to need to measure their EF. The last point is, because the overall value of the history and physical is not perfect, consider adding the BNP, especially if you're in a lower prevalent setting and you just want to be reassured that they don't have heart failure. >> Thank you, Dr. Badgett, for this overview of heart failure. And for more information about this topic, JAMAevidence subscribers can consult JAMAevidence's online chapter on heart failure in the Rational Clinical Examination which also includes updated information from Dr. Badgett.
This has been Joan Stephenson of JAMA interviewing Dr. Bob Badgett about heart failure for JAMAevidence.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News & Perspectives section. Today, I have the pleasure of speaking with Dr. Bob Badgett about heart failure. Dr. Badgett, why don't you introduce yourself to our listeners? >> Thank you. So my name is Bob Badgett and I'm in the Division of Hospital Medicine at the University of Texas Health Science Center in San Antonio. >> Dr. Badgett, what are the reference standard tests for heart failure? >> Well, right at the beginning, we start with the most difficult question. I think it's best to go back to what Braunwald says about his definition, which is, "Heart failure is a pathophysiological state which abnormality of cardiac function is responsible for failure of the heart to pump blood at a rate commensurate with the requirements of the metabolising tissues, or it will only do so with a filling pressure that's elevated." The problem with this definition is it's very hard to measure in clinical practice.
And we also have to remember that there's two different underlying pathophysiologies. Is it systolic heart failure or diastolic heart failure? So to try to implement this definition, a very good option for the reference test is a high left ventricular end diastolic pressure or LVEDP in the absence of a noncardiac reason for a high LVEDP. But then it gets a little more complicated. The LVEDP is a nice measure acutely during heart failure because it's fairly reliable that it's going to be elevated and it's abnormal both in systolic and diastolic dysfunction.
The problem with it is the LVEDP and most every other measure for heart failure is normal after treatment when the patient is asymptomatic. So for that setting, we now turn to the echocardiography. And as we all know it's a good test for measuring systolic dysfunction by looking at the ejection fraction, but the ability to measure diastolic dysfunction is uncertain and still improving. The most recent studies suggest that it may be as good as 80% sensitive for detecting diastolic dysfunction, but these aren't widely replicated studies.
So the next step is to define diastolic dysfunction then and the cause of difficulties with the echo. And you may make a good definition is high LVEDP, either now or in the past, but with a measured normal ejection fraction. So those are the definitions I would propose. Looking at the LVEDP and then dividing up the patients by what is their ejection fraction. Keep an eye out for improving measures of diastolic dysfunction by echo.
At this point, I should note that JAMA has two reviews of heart failure. The one we're discussing today compares a clinical exam to one of these objective measures of heart failure. The other review compares a clinical examination to expert determination of heart failure after comprehensive heart review. And there's pros and cons of these different definitions. >> Dr. Badgett, what do we know about the prevalence of heart failure and are there important demographic characteristics? >> Well, it's becoming more prevalent and more prevalent in situations where you have risk factors such as ischemic heart disease, hypertension.
Regarding the demographic characteristics, the things that are important to remember is that older and obese patients are a little bit more likely to have diastolic dysfunction. Then another important fact is that race, specifically African Americans, knowing that may not help you determine if they have heart failure, but it may help you decide how to treat them because African Americans are more likely to have polymorphisms of the G protein-coupled cell surface receptor kinase, so they may more likely need nitrates and hydralazine, still an evolving area of research.
And the other important thing, somewhat about demographics, is once a patient is known to have systolic dysfunction, your interpretation of their findings should change in two ways. First, they now have a higher prevalence of congestion and so you should ramp up your assessment of congestion whenever you see them. And second, any clinical findings that are based on cardiomegaly, such as a point -- a maximal endpoint, the PMI on the physical exam or the chest x-ray, looking at cardiomegaly now have to be seen differently because they're persistent findings and it won't come and go with treatment of heart failure.
>> Which symptoms, when present, increase the probability of a diagnosis of heart failure? >> Well, from our review of the studies, only two findings, dyspnea and orthopnea, are consistently, independently predictive findings of heart failure. >> Which history and physical examination findings are helpful when detecting heart failure, and which findings are not as helpful? >> Let's divide this question into which type of heart failure we're discussing. So let's first look at, simply, is their filling pressure increased?
In the findings that are most consistently helpful, first a radiographic finding, which is do they have redistribution on the chest x-ray? Then a physical finding, do they have jugular venous distention? Now in the somewhat helpful findings, these are ones that are shown in many but not all studies to be helpful, are dyspnea and orthopnea like we already mentioned, but then, in addition, tachycardia, low blood pressure, low proportional pulse pressure, S3, rales, abdominal jugular reflux.
And now going back to the radiograph, cardiomegaly. And then the last finding that's worth mentioning for increased filling pressure is edema, a tricky finding, not helpful when absent, but may be helpful when present. Now the second question is if you decide to have abnormal filling pressure or separately, you're just thinking about ejection fraction, trying to determine who has abnormal ejection fraction, the very helpful findings are radiographic cardiomegaly or redistribution.
Going to the EKG is anterior Q-waves or left bundle branch block. Now going to the physical exam, abnormal apical impulse and, again, pretty much the same abnormal vital signs, tachycardia, low blood pressure, low proportional pulse pressure. And then the other findings, S3, rales, dyspnea, history of infarction, and then jugular venous distention and edema as before. Pretty similar findings compared to increased filling pressure because there's a strong correlation with your filling pressure and your ejection fraction, but not quite the same findings.
>> How can you distinguish diastolic from systolic dysfunction? >> This becomes the third type, or definition of heart failure to think about. So which ones have diastolic dysfunction? The best finding for this is if during the episode of heart failure, the patient has an elevated blood pressure at the bedside. So recall that, in systolic dysfunction, they're more likely to have a low blood pressure. Now the patient is more likely to have an elevated blood pressure.
>> Would you tell us how to incorporate the information from the BNP essay with the findings on the clinical examination? >> Well, the BNP is a new tool that's come out since we first did our review. So I've had to think about how to use it, incorporating it with other findings. So because there are not very good multivariate studies of using the BNP with many of the other findings, looking at one of these objective reference standard measures of heart failure, I think the best way to do this is with a [inaudible] analysis.
So if you go to the BNP studies, it looks like the BNP is much more sensitive than specific. So sensitivity is at least 90%, very nice. Specificity is mediocre, around 70%. So using the nomenclature for diagnostic tests, we would call this a "SnNOut." And to remind you, SnNOut has two ns, an intentional misspelling, meaning findings that are highly sensitive, when negative help rule out.
So the BNP, when negative, helps rule out. When positive, it kind of depends on just how elevated it is. So if you construct the two-by-two table using that sensitivity and specificity, you can see that a BNP is negative -- if negative, is helpful as long as the pretest probability of heart failure is less than 25%. So, therefore, I combine it with my other findings in the following way. When my findings make me think that, overall, the chance of heart failure is less than half, or I should actually say less than 25% or so, I think the BNP is helpful because then, if it's normal, less than 50 or maybe less than 100, I feel fairly certain that the patient doesn't have heart failure.
So it's best in low prevalent situations at ruling out heart failure. >> Is there anything else new since your review that JAMAevidence users should know about heart failure in relation to the physical examination? >> Well, several new things have come out, and they can be some interesting topics to keep an eye out for. First, because we're having better measures of diastolic dysfunction, so now we can use the echo as a better reference standard in our studies, it's starting to look like the fourth heart sound which, in the past I've always thought to be a boring finding in the setting of heart failure, it may turn out to have some role as a correlate with diastolic dysfunction.
But it's hard to say anything certain as the research is still emerging on that. But it looks like it may correlate with diastolic dysfunction until the diastolic dysfunction gets severe, at which time the fourth heart sound may lose its ability. The second emerging topic that's come out is hemodynamic profiling heart failure patients into different groups that may benefit from different treatments. And this all hinges on the idea that the heart failure patient who is also having hypoperfusion by physical exam may need specific treatments such as reducing some of their medications, beta blockers and ACE inhibitors, temporarily while you improve their fluid state, and then restarting these medicines later.
So this hinges, then, on how good is the physical findings at detecting hypoperfusion? And, unfortunately, I don't think they've been studied as well as other findings for heart failure. Four findings are proposed The proportional pulse pressure less than 25%, delayed capillary refilling, [inaudible] modeling and [inaudible] temperature. And I think I can safely say, in isolation, none of these findings are great, but unfortunately, they haven't been well studied in a combination.
So looking out for that. And the other thing to look out for is that there may be easy, non-invasive measures of hypoperfusion such as the oxygen saturation of the thenar eminence or by using a blood test of the lactate clearance. Then the treatment part of this question still needs more examination. So how well do these different profiles need different treatments? Then the last topic to keep an eye out for is using the physical examination not as a diagnostic test, but as a target measure for treating heart failure.
And now that the BNP is available, there's a lot of tests coming out on using the BNP as a target for your treating heart failure, so you treat to a certain BNP. Now not the thrust of these studies, but to me a very interesting side feature of the studies is that they're usually comparing targeting the BNP to targeting the physical exam. And so the better done studies standardize a physical exam with the Framingham score for heart failure, and the studies aren't perfectly clear yet but they suggest as you do an objective evaluation of heart failure with the Framingham score, you might be able to target your heart failure treatment just as well as using the BNP.
Interestingly, the Framingham scores they look at allow you to have a score of 2 or less, which means you can have one finding of heart failure and, if the patient is otherwise asymptomatic, it doesn't mean you have to continue treating them. I think it's an interesting area to keep looking for. And so those are the three areas that may change over the next few years. >> Dr. Badgett, are there any key points about heart failure that you'd like to emphasize to our listeners? >> So the first summary conclusion that, even when we're very careful about how we interpret our findings, which findings we select to use in our assessment, that our summary measures for heart failure are not that great.
Our likelihood ratio of positive, when we pooled our favorite studies, was 4.5. Our negative likelihood ratio was 0.45. So while there's some ability for the clinical evaluation, it's not that strong that, by itself, it can say yes or no heart failure. So, first, you should have a very low threshold to add the electrocardiogram and the chest x-ray to your evaluation of someone with heart failure. Second, even with that, if you're in a setting where the prevalence of heart failure is enriched, such as someone with a recent or anytime history of myocardial infarction or someone who you're trying to evaluate their fluid status and they already have known systolic dysfunction, you need to recognize the increased prevalence of heart failure and, in these settings, you may have to get a further test.
So the patient after infarction, you're probably going to need to measure their EF. The last point is, because the overall value of the history and physical is not perfect, consider adding the BNP, especially if you're in a lower prevalent setting and you just want to be reassured that they don't have heart failure. >> Thank you, Dr. Badgett, for this overview of heart failure. And for more information about this topic, JAMAevidence subscribers can consult JAMAevidence's online chapter on heart failure in the Rational Clinical Examination which also includes updated information from Dr. Badgett.
This has been Joan Stephenson of JAMA interviewing Dr. Bob Badgett about heart failure for JAMAevidence.
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