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Extent of jugular venous distension and lower extremity edema are the best tools from history and physical examination to identify heart failure exacerbation

Ausmaß der jugularvenösen Distension und Ödeme der unteren Extremität als beste Parameter aus der Anamnese und körperlichen Untersuchung zur Identifizierung einer Verschlechterung der Herzinsuffizienz

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Abstract

Introduction

We aimed to identify the best tools from history and physical examination that predict severity of heart failure (HF) exacerbation among patients with an ejection fraction (EF) ≤ 30%.

Methods

Patients enrolled in the ESCAPE trial were divided into tertiles according to the combined value of pulmonary capillary wedge pressure (PCWP) and right atrial pressure (RAP) which we used as a marker of volume loading of both pulmonary and systemic compartments. Variables of congestion from history and physical examination were examined across tertiles.

Results

There were significant differences across tertiles (tertile 1: PCWP + RAP < 31 mm Hg, tertile 2: PCWP + RAP 31–42 mm Hg and tertile 3: PCWP + RAP > 42 mm Hg) with respect to baseline B‑type natriuretic peptide (P = 0.016), blood urea nitrogen (P = 0.022), sodium (P = 0.015), left ventricular ejection fraction (P = 0.005), and inferior vena cava diameter during inspiration (P < 0.001) and expiration (P < 0.001). With respect to variables of congestion from history and physical examination, we found significant differences across tertiles predominantly in signs of right sided failure, specifically, the frequency of jugular venous distension (JVD, P < 0.001) and JVD > 12 cmH2O (p < 0.001), lower extremity edema (P = 0.001) and lower extremity edema of at least grade 2 + (P = 0.029), and positive hepatojugular reflux (HJR, P = 0.022) but no differences in patients’ symptoms such as degree of dyspnea, orthopnea or fatigue. With regards to post-discharge outcomes, there was a significant difference across tertiles in all-cause mortality (P = 0.029) and rehospitalization for HF (P = 0.031) at 6 months following randomization. Receiver operator characteristic curves showed that admission PCWP + RAP had an area under the curve of 0.623 (P = 0.0075) and 0.617 (P = 0.0048), respectively, in predicting 6‑month all-cause mortality and rehospitalization for HF.

Conclusion

The presence and extent of JVD and lower extremity edema, and a positive HJR are better than other signs and symptoms in identifying severity of HF exacerbation among patients with EF ≤ 30%.

Zusammenfassung

Einleitung

Ziel ist es, die besten Instrumente aus der Anamnese und körperlichen Untersuchung zu identifizieren, welche die Schwere der Verschlimmerung einer Herzinsuffizienz (HF) bei Patienten mit einer Ejektionsfraktion (EF) ≤ 30 % vorhersagen.

Methoden

Die in die ESCAPE-Studie eingeschlossenen Patienten wurden in Terzilen eingeteilt hinsichtlich der kombinierten Werte des pulmonalkapillären Verschlussdrucks („pulmonary capillary wedge pressure“, PCWP) und des rechtsatrialen Drucks („right atrial pressure“, RAP), die als Marker des Ladevolumens sowohl der pulmonalen als auch der systemischen Kompartimente verwendet wurden. Variablen der Kongestion aus der Anamnese und körperlichen Untersuchung wurden in allen Terzilen untersucht.

Ergebnisse

Zwischen den Terzilen gab es signifikante Unterschiede (Terzil 1: PCWP + RAP < 31 mmHg, Terzil 2: PCWP + RAP 31–42 mmHg und Terzil 3: PCWP + RAP > 42 mmHg) hinsichtlich des Ausgangswerts des natriuretischen Peptids Typ B (p = 0,016), des Harnstoffstickstoffs im Blut (p = 0,022), des Natriums (p = 0,015), der linksventrikulären Ejektionsfraktion (p = 0,005) sowie des Durchmessers der V. cava inferior während der Einatmung (p < 0,001) und Ausatmung (p < 0,001). Bezüglich der Variablen einer Kongestion aus der Anamnese und körperlichen Untersuchung stellten wir vor allem bei Anzeichen der Rechtsherzinsuffizienz, insbesondere bei der Häufigkeit einer jugularvenösen Distension (JVD; p < 0,001) und JVD > 12 cmH2O (p < 0,001), bei Ödemen der unteren Extremität (p = 0,001), Ödemen der unteren Extremität > Grad 2 (p = 0,029) und positivem hepatojugulärem Reflux (HJR; p = 0,022), signifikante Unterschiede bei den Terzilen fest. Bei den Symptomen der Patienten, wie dem Grad der Dyspnoe, Orthopnoe oder Fatigue, gab es jedoch keine Unterschiede. Bezüglich der Ergebnisse nach Entlassung gab es einen signifikanten Unterschied zwischen den Terzilen in der Mortalität jeglicher Ursache (p = 0,029) und Rehospitalisation wegen HF (p = 0,031) jeweils 6 Monate nach der Randomisierung. Die Receiver-Operating-Characteristic-Kurven zeigten, dass der Ausgangswert von PCWP + RAP bei der Prädiktion der Mortalität jeglicher Ursache und Rehospitalisation wegen HF eine „area under the curve“ von 0,623 (p = 0,0075) bzw. 0,617 (p = 0,0048) zeigte.

Schlussfolgerung

Vorliegen und Ausmaß von JVD und Ödemen der unteren Extremität sowie ein positiver HJR sind zur Identifizierung der Schwere einer HF-Verschlechterung bei Patienten mit einer EF ≤ 30 % besser geeignet als andere Anzeichen und Symptome.

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Acknowledgements

The ESCAPE trial was conducted and supported by the NHLBI in collaboration with the ESCAPE study Investigators. This article was prepared using a limited access dataset obtained from the NHLBI and does not necessarily reflect the opinions or views of the ESCAPE trial investigators or the NHLBI. We would like to thank Dr. Richard Charnigo for his valuable statistical contribution.

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Authors and Affiliations

  1. Internal Medicine Department, Mercy Medical Center, Clinton, IA, USA

    H. R. Omar M.D

  2. Division of Cardiovascular Medicine, Linda and Jack Gill Heart Institute, University of Kentucky, Lexington, KY, USA

    M. Guglin M.D

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Correspondence to H. R. Omar M.D.

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H.R. Omar and M. Guglin declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Omar, H.R., Guglin, M. Extent of jugular venous distension and lower extremity edema are the best tools from history and physical examination to identify heart failure exacerbation. Herz 43, 752–758 (2018). https://doi.org/10.1007/s00059-017-4623-9

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  • DOI: https://doi.org/10.1007/s00059-017-4623-9

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