Abstract
Background
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.
Methods
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.
Results
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).
Conclusions
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.
Keywords
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Article info
Publication history
Published online: September 23, 2011
Footnotes
Funding: None.
Conflict of Interest: The authors report no conflicts of interest or financial disclosures.
Authorship: All authors had access to the data and played a role in writing this manuscript.
Identification
Copyright
© 2011 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Bedside Assessment of Cardiac Hemodynamics: Role of the Simple Valsalva ManeuverThe American Journal of MedicineVol. 125Issue 8
- PreviewMore 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.
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