Clinical research study| Volume 124, ISSUE 11, P1051-1057, November 2011

Bedside Assessment of Cardiac Hemodynamics: The Impact of Noninvasive Testing and Examiner Experience

Published:September 23, 2011DOI:



      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.


      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.


      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).


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Leier C.V.
        • Chatterjee K.
        The physical examination in heart failure—Part I.
        Congest Heart Fail. 2007; 13: 41-47
        • Leier C.V.
        • Chatterjee K.
        The physical examination in heart failure—Part II.
        Congest Heart Fail. 2007; 13: 99-104
        • Drazner M.H.
        • Hellkamp A.S.
        • Leier C.V.
        • et al.
        Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial.
        Circ Heart Fail. 2008; 1: 170-177
        • Cook D.J.
        • Simel D.L.
        The Rational Clinical Examination.
        JAMA. 1996; 275: 630-634
        • Drazner M.H.
        • Rame J.E.
        • Stevenson L.W.
        • Dries D.L.
        Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure.
        N Engl J Med. 2001; 345: 574-581
        • Mangione S.
        • Nieman L.Z.
        Cardiac auscultatory skills of internal medicine and family practice trainees.
        JAMA. 1997; 278: 717-722
        • Cook D.J.
        Clinical assessment of central venous pressure in the critically ill.
        Am J Med Sci. 1990; 299: 175-178
        • Davison R.
        • Cannon R.
        Estimation of central venous pressure by examination of jugular veins.
        Am Heart J. 1974; 87: 279-282
        • Brennan J.M.
        • Blair J.E.
        • Goonewardena S.
        • et al.
        A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure.
        Am J Cardiol. 2007; 99: 1614-1616
        • Eisenberg P.R.
        • Jaffe A.S.
        • Schuster D.P.
        Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.
        Crit Care Med. 1984; 12: 549-553
        • Ewy G.A.
        The abdominojugular test: technique and hemodynamic correlates.
        Ann Intern Med. 1988; 109: 456-460
        • Stoelting R.K.
        Evaluation of external jugular venous pressure as a reflection of right atrial pressure.
        Anesthesiology. 1973; 38: 291-294
        • Badgett R.G.
        • Lucey C.R.
        • Mulrow C.D.
        Can the clinical examination diagnose left-sided heart failure in adults?.
        JAMA. 1997; 277: 1712-1719
        • Butman S.M.
        • Ewy G.A.
        • Standen J.R.
        • Kern K.B.
        • Hahn E.
        Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension.
        J Am Coll Cardiol. 1993; 22: 968-974
        • Connors Jr, A.F.
        • Dawson N.V.
        • Shaw P.K.
        • Montenegro H.D.
        • Nara A.R.
        • Martin L.
        Hemodynamic status in critically ill patients with and without acute heart disease.
        Chest. 1990; 98: 1200-1206
        • Goonewardena S.N.
        • Blair J.E.
        • Manuchehry A.
        • et al.
        Use of hand carried ultrasound, B-type natriuretic peptide, and clinical assessment in identifying abnormal left ventricular filling pressures in patients referred for right heart catheterization.
        J Card Fail. 2010; 16: 69-75
        • Stevenson L.W.
        • Perloff J.K.
        The limited reliability of physical signs for estimating hemodynamics in chronic heart failure.
        JAMA. 1989; 261: 884-888
        • Bayram M.
        • Yancy C.W.
        Transthoracic impedance cardiography: a noninvasive method of hemodynamic assessment.
        Heart Fail Clin. 2009; 5: 161-168
        • Connors Jr, A.F.
        • McCaffree D.R.
        • Gray B.A.
        Evaluation of right-heart catheterization in the critically ill patient without acute myocardial infarction.
        N Engl J Med. 1983; 308: 263-267
        • Fein A.M.
        • Goldberg S.K.
        • Walkenstein M.D.
        • Dershaw B.
        • Braitman L.
        • Lippmann M.L.
        Is pulmonary artery catheterization necessary for the diagnosis of pulmonary edema?.
        Am Rev Respir Dis. 1984; 129: 1006-1009
        • Zile M.R.
        • Bennett T.D.
        • St John Sutton M.
        • et al.
        Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures.
        Circulation. 2008; 118: 1433-1441
        • Abraham W.T.
        • Adamson P.B.
        • Bourge R.C.
        • et al.
        Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial.
        Lancet. 2011; 37: 658-666
        • Nagueh S.F.
        • Appleton C.P.
        • Gillebert T.C.
        • et al.
        Recommendations for the evaluation of left ventricular diastolic function by echocardiography.
        J Am Soc Echocardiogr. 2009; 22: 107-133
        • Mohammed A.A.
        • Januzzi Jr., J.L.
        Natriuretic peptides in the diagnosis and management of acute heart failure.
        Heart Fail Clin. 2009; 5: 489-500
        • Iwanaga Y.
        • Nishi I.
        • Furuichi S.
        • et al.
        B-type natriuretic peptide strongly reflects diastolic wall stress in patients with chronic heart failure: comparison between systolic and diastolic heart failure.
        J Am Coll Cardiol. 2006; 47: 742-748
        • Ommen S.R.
        • Nishimura R.A.
        • Appleton C.P.
        • et al.
        Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study.
        Circulation. 2000; 102: 1788-1794
        • Kasner M.
        • Westermann D.
        • Steendijk P.
        • et al.
        Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study.
        Circulation. 2007; 116: 637-647
        • Mullens W.
        • Borowski A.G.
        • Curtin R.J.
        • Thomas J.D.
        • Tang W.H.
        Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure.
        Circulation. 2009; 119: 62-70
        • Maeder M.T.
        • Thompson B.R.
        • Brunner-La Rocca H.P.
        • Kaye D.M.
        Hemodynamic basis of exercise limitation in patients with heart failure and normal ejection fraction.
        J Am Coll Cardiol. 2010; 56: 855-863
        • Pepine C.J.
        • Hill J.A.
        • Lambert C.R.
        Diagnostic and Therapeutic Cardiac Catheterization.
        3rd edition. Lippincott Williams & Wilkins, Philadelphia1998
        • Pencina M.J.
        • D'Agostino Sr, R.B.
        • D'Agostino Jr, R.B.
        • Vasan R.S.
        Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.
        Stat Med. 2008; 27 (discussion 207-212): 157-172
        • Goldsmith S.R.
        • Brandimarte F.
        • Gheorghiade M.
        Congestion as a therapeutic target in acute heart failure syndromes.
        Prog Cardiovasc Dis. 2010; 52: 383-392
        • Fonarow G.C.
        Pharmacologic therapies for acutely decompensated heart failure.
        Rev Cardiovasc Med. 2002; 3: S18-S27
        • Borlaug B.A.
        • Nishimura R.A.
        • Sorajja P.
        • Lam C.S.
        • Redfield M.M.
        Exercise hemodynamics enhance diagnosis of early heart failure with preserved ejection fraction.
        Circ Heart Fail. 2010; 3: 588-595
        • Capomolla S.
        • Ceresa M.
        • Pinna G.
        • et al.
        Echo-Doppler and clinical evaluations to define hemodynamic profile in patients with chronic heart failure: accuracy and influence on therapeutic management.
        Eur J Heart Fail. 2005; 7: 624-630
        • Temporelli P.L.
        • Scapellato F.
        • Eleuteri E.
        • Imparato A.
        • Giannuzzi P.
        Doppler echocardiography in advanced systolic heart failure: a noninvasive alternative to Swan-Ganz catheter.
        Circ Heart Fail. 2010; 3: 387-394
        • Drazner M.H.
        • Hamilton M.A.
        • Fonarow G.
        • Creaser J.
        • Flavell C.
        • Stevenson L.W.
        Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure.
        J Heart Lung Transplant. 1999; 18: 1126-1132

      Linked Article

      • Bedside Assessment of Cardiac Hemodynamics: Role of the Simple Valsalva Maneuver
        The American Journal of MedicineVol. 125Issue 8
        • Preview
          More than a decade has passed since the publication of my editorial entitled “Diagnosing Heart Failure by the Valsalva Maneuver. Isn't It Finally Time?”1 The physiology of the Valsalva maneuver was reviewed and reference made to the use of a simple bedside technique, using only stethoscope and sphygmomanometer, to assess the degree of left ventricular dysfunction in patients. Sensitivity and specificity of an abnormal arterial pressure response during the Valsalva maneuver for left ventricular dysfunction were demonstrably superior to any other finding on physical examination and chest roentgenogram.
        • Full-Text
        • PDF