Abstract
Purpose
To determine the independent prognostic value of a third heart sound (S3) 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 ≤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 S3 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 S3 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 S3 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.
Keywords
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References
- Importance of elevated jugular venous pressure and a third heart sound in patients with heart failure.N Engl J Med. 2001; 345: 574-581
- Studies of Left Ventricular Dysfunction (SOLVD)—rationale, design and methods.Am J Cardiol. 1990; 66: 315-322
- ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary.J Am Coll Cardiol. 2001; 38: 2101-2113
- Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions.N Engl J Med. 1992; 327: 685-691
- Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure.N Engl J Med. 1991; 325: 293-302
- Prognostic impact of diabetes mellitus in patients with heart failure according to the etiology of left ventricular systolic dysfunction.J Am Coll Cardiol. 2001; 38: 421-428
- Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials.J Am Coll Cardiol. 1998; 32: 695-703
- Racial differences in the outcome of left ventricular dysfunction.N Engl J Med. 1999; 340: 609-616
- Survival Analysis Using the SAS System: A Practical Guide. SAS Institute, Cary, NC1995
- Survival Analysis: A Self Learning Text. Springer-Verlag, New York1996
- Incidence of the physiological third heart sound.BMJ. 1952; : 853-855
- The accuracy and interobserver agreement in detecting the “gallop sounds” by cardiac auscultation.Chest. 1998; 114: 1283-1288
- Interobserver agreement by auscultation in the presence of a third heart sound in patients with congestive heart failure.Chest. 1987; 91: 870-873
- Symptoms and signs of heart failure in patients with myocardial infarction.Eur Heart J. 1989; 10: 1017-1028
- Pathophysiologic determinants of third heart sounds.Am J Med. 2001; 111: 96-102
- Accuracy and reliability of apical S3 gallop detection.J Gen Intern Med. 1995; 10: 455-457
- Audibility of an artificial third heart sound in relation to its frequency, amplitude, delay from the second heart sound and the experience of the observer.Am J Cardiol. 1984; 53: 1169-1172
- Mechanical correlates of the third heart sound.J Am Coll Cardiol. 1992; 19: 450-457
- Hemodynamic correlates of the third heart sound during the evolution of chronic heart failure.J Am Coll Cardiol. 1993; 21: 419-423
- Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med. 1984; 12: 549-553
- Comparison of estimates of right atrial pressure by physical examination and echocardiography in patients with congestive heart failure and reasons for discrepancies.Am J Cardiol. 1997; 80: 1615-1618
- Evaluation of right-heart catheterization in the critically ill patient without myocardial infarction.N Engl J Med. 1983; 308: 263-267
- The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey.Ann Intern Med. 1993; 119: 47-54
- Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency.JAMA. 1997; 278: 717-722
- Assessing housestaff diagnostic skills using a cardiology patient simulator.Ann Intern Med. 1992; 117: 751-756
- Physician-performed point-of-care echocardiography using a laptop platform compared with physical examination in the cardiovascular patient.J Am Coll Cardiol. 2001; 37: 2013-2018
- The jugular venous pulse and third heart sound in patients with heart failure.N Engl J Med. 2001; 345: 612-614
- Diastolic properties of the left ventricle in normal adults and in patients with third heart sounds.Circulation. 1984; 69: 1070-1078
- Origin of the third heart sound: comparison of ventricular wall dynamics in hyperdynamic and hypodynamic types.J Am Coll Cardiol. 1985; 5: 268-272
- Restrictive left ventricular filling pattern in dilated cardiomyopathy assessed by Doppler echocardiography.J Am Coll Cardiol. 1993; 22: 808-815
- Pulsed Doppler evaluation of left ventricular filling in subjects with pathologic and physiologic third heart sound.Eur Heart J. 1990; 11: 500-508
- Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy. Relation to symptoms and prognosis.Circulation. 1994; 90: 2772-2779
- Prognostic value of Doppler transmitral flow patterns in patients with congestive heart failure.J Am Coll Cardiol. 1994; 24: 132-139
- Bedside cardiovascular examination in patients with severe chronic heart failure.J Am Coll Cardiol. 1993; 22: 968-974
- Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure.Am J Med. 1991; 90: 353-359
- Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure.J Heart Lung Transplant. 1999; 18: 1126-1132
- The limited reliability of physical signs for estimating hemodynamics in chronic heart failure.JAMA. 1989; 261: 884-888
- Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population.Lancet. 1997; 350: 829-833
- The abdominojugular test.Ann Intern Med. 1988; 109: 456-460
Article info
Publication history
Accepted:
November 20,
2002
Received in revised form:
November 1,
2002
Received:
June 27,
2002
Footnotes
☆Drs. Drazner, Rame, and Dries received support from the Donald W. Reynolds Cardiovascular Clinical Research Center, Dallas, Texas. Dr. Drazner was the recipient of a Doris Duke Clinical Scientist Development Award from the Doris Duke Charitable Foundation, New York, New York. The National Heart, Lung, and Blood Institute, Bethesda, Maryland, sponsored the Studies of Left Ventricular Dysfunction (SOLVD) prevention trial. Merck, Whitehouse Station, New Jersey, supplied the study drug for the SOLVD prevention trial.
Identification
Copyright
© 2003 Excerpta Medica Inc. Published by Elsevier Inc. All rights reserved.
