Identifying Discordance of Right- and Left-Ventricular Filling Pressures in Patients With Heart Failure by the Clinical Examination

Abstract

Background : In approximately 25% of patients with heart failure and reduced left-ventricular ejection fraction (HFrEF), right-ventricular (RV) and left-ventricular (LV) filling pressures are discordant (i.e., one is elevated while the other is not). Whether clinical assessment allows detection of this discordance is unknown. We sought to determine the agreement of clinically- versus invasively-determined patterns of ventricular congestion. Methods : In 156 HFrEF subjects undergoing invasive hemodynamic assessment, we categorized patterns of ventricular congestion (no congestion, RV only, LV only, or both) based on clinical findings of RV (jugular venous distention, JVD) or LV (hepatojugular reflux, orthopnea, or bendopnea) congestion. Agreement between clinically and invasively determined [RV congestion if right atrial pressure (RAP) ≥10 mmHg and LV congestion if pulmonary capillary wedge pressure (PCWP) ≥22 mmHg)] categorizations was the primary endpoint. Results : The frequency of clinical patterns of congestion was: 51% no congestion, 24% both RV and LV, 21% LV only, and 4% RV only. JVD had excellent discrimination for elevated RAP (C=0.88). However, agreement between clinical and invasive congestion patterns was poor, λ=0.44 (95% CI 0.34-0.55). While those with no clinical congestion usually had low RAP and PCWP (67/79, 85%), over one-half (24/38, 64%) with isolated LV clinical congestion had PCWP <22 mmHg, most (5/7, 71%) with isolated RV clinical congestion had PCWP ≥22 mmHg, and ∼one-third (10/32, 31%) with both RV and LV clinical congestion had elevated RAP but PCWP <22 mmHg. Conclusions : While clinical examination allows accurate detection of elevated RAP, it does not allow accurate detection of discordant RV and LV filling pressures.

Prognostic Role of Subclinical Congestion in Heart Failure Outpatients: Focus on Right Ventricular Dysfunction

“…However, half of our "SubC" patient cohort showed signs of elevated central venous pressure without showing peripheral OED. Therefore, according to recent findings [14], JVD and HJR represent clinical signs with good specificity for identifying elevated RAP; when they are detectable, they it is advisable for the clinician to investigate signs of subclinical congestion through instrumental methods. By analyzing the morpho-functional parameters of the right chambers, right atrial dilation is found to be closely associated with congestion, both clinical and instrumental.…”

“…PE is the cornerstone of outpatient evaluation, however it often lacks accuracy compared with other instrumental evaluations [13,14], potentially leading to under/overtreatment, especially regarding diuretic strategies [6,15]. The benefits of an integrated approach combining natriuretic peptides [16] such as the easily reproducible US signs [7,12,17] and implantable device monitoring [18] are still a matter of debate [19].…”

Implementation of remote monitoring strategies to improve chronic heart failure management

“…If patients continue to have end-organ dysfunction and persistently elevated PAD readings, then they should be referred to an advanced heart failure center for consideration of advanced heart failure therapies if deemed appropriate. Other situations for considering PAP sensor are in those with challenging assessment of intracardiac pressures and perfusion [32,33] and in those whose renal function and blood pressures are sensitive to GDMT or other clinical changes.…”

Disentangling the Pulmonary Capillary Wedge Pressure From the Pulmonary Artery Pressure as the Hemodynamic Underpinning of Bendopnea

“…The participants with HFrEF have been described. 4 PH participants were predominantly referred for PAC by our PH Clinic. Institutional Review Board approval and informed consent were obtained.…”

“…Our findings have clinical utility. Specifically, although bendopnea can detect an elevated PCWP in HFrEF, 4 bendopnea should not be used to assess whether PAPs are elevated in patients with a history of precapillary PH.…”