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ABSTRACT & COMMENTARY
By Michael H. Crawford, MD
Professor of Medicine, Chief of Clinical Cardiology, University of California, San Francisco
This article originally appeared in the April 2014 issue of Clinical Cardiology Alert. It was peer reviewed by Ethan Weiss, MD, Assistant Professor of Medicine, Division of Cardiology and CVRI, University of California, San Francisco. Dr. Crawford reports no financial relationships relevant to this field of study, and Dr. Weiss is a scientific advisory board member for Bionovo.
Source: Caldentey G, et al. Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: Insights from the AF-CHF Trial (Atrial Fibrillation and Chronic Heart Failure). JACC Heart Fail 2014;2:15-23.
These investigators from the Montreal Heart Institute asked the question of whether the physical examination was still of value in the modern era of heart failure management that includes the use of biomarkers and echocardiography. They employed the patient population in a trial of heart failure and non-permanent atrial fibrillation (AF) randomized to a rhythm control vs. rate control strategies. The study showed no differences in outcome between the two groups. The physical examination findings were evaluated retrospectively and four signs were studied: peripheral edema, jugular venous distention (JVD), third heart sound, and pulmonary rales. The patients were followed for up to 6 years and the primary outcome was cardiovascular (CV) mortality. Secondary outcomes included all-cause mortality, heart failure-related mortality, sudden death, and heart failure hospitalizations. Of the 1376 patients enrolled, all but seven had data on all four of the physical exam findings. At enrollment, 31% had peripheral edema, 22% had JVD, 15% a third sound, and 13% had rales. Over a mean follow-up of 37 months, 32% died and 25% had at least one heart failure hospitalization. In the univariate analysis, all four of the physical findings were associated with increased CV mortality (hazard ratios [HRs], 1.5-1.9; all P < 0.004). On multivariate analysis up against laboratory tests and echocardiographic parameters, peripheral edema (HR, 1.25; 95% confidence interval [CI], 1.00-1.57; P < 0.05) and rales (HR, 1.4; 95% CI, 1.08-1.86; P < 0.02) remained predictive of CV mortality. Peripheral edema was independently associated with all-cause mortality and heart failure-related death. Rales were independently associated with heart failure-related death and hospitalization. JVD or a third heart sound were not independently associated with any CV outcome. The authors concluded that physical examination signs of congestion are important prognostic indicators in the modern therapeutic milieu of congestive heart failure.
In the current era where the serial use of echocardiography, brain natriuretic peptide levels, and measures of renal function are often the drivers of therapeutic decisions in heart failure management, it is interesting to see that signs of congestive heart failure on physical examination are still useful predictors of outcome. This study involved patients with left ventricular ejection fractions < 35% and heart failure symptoms within 6 months of enrollment. They were on modern therapy: 86% on angiotensin-converting enzyme inhibitors, 79% on beta-blockers, and 45% on aldosterone antagonists. However, it is not known how many had ventricular pacing. Also, the patients all had a history of non-permanent atrial fibrillation and some were on antiarrhythmic drugs such as amiodarone. Whether the results would apply to other less sick or less well treated populations is unknown, but previous studies would suggest that they would.
The major limitation of this study is that it is observational and cannot be adjusted for unknown confounders. For example, rales can be caused by lung disease; a third sound may be due to marked mitral regurgitation; and edema can be due to venous insufficiency. Also, this is a retrospective analysis of a study designed for another purpose, so it is difficult to know how well the physical examination was conducted. Unless each patient is put in the left lateral position and the bell of the stethoscope used, third heart sounds can be missed. In addition, JVD is notoriously hard to determine. Perhaps this is why rales and edema were more predictive than the third sound and JVD.
The new Accreditation Council for Graduate Medical Education mandated resident evaluation system emphasizes the attainment of milestones. At my institution, we are including the mastery of identifying these four physical findings as milestones that the residents should achieve.