Download Observation Is Never Obsolete∗

JACC: Heart Failure
Ó 2014 by the American College of Cardiology Foundation
Published by Elsevier Inc.
EDITORIAL COMMENT
Observation Is Never Obsolete*
Anju Nohria, MD, Lynne Warner Stevenson, MD
Boston, Massachusetts
The hallmark signs and symptoms of heart failure reflect
congestion, the manifestation of elevated ventricular filling
pressures. These are the symptoms that trigger heart failure
hospitalizations, 80% to 95% of which are characterized by
congestion without hypoperfusion (the “warm and wet”
profile) (1). Therapy during acute decompensated heart
failure focuses on relief of these symptoms and redesign of
a regimen to prevent their recurrence. Implantable hemodynamic monitoring has revealed that intracardiac filling
pressures usually increasing more than 2 weeks before
symptoms lead to recurrent hospitalization, whether with
reduced or preserved left ventricular ejection fraction (2,3).
Treatment is not limited to symptom relief, because chronic
congestion also contributes to disease progression. Elevated
left-sided filling pressures lead to chronic remodeling,
worsened by mitral annular dilation with increased regurgitant volume, pulmonary hypertension, and elevation of
right ventricular afterload (4). Backward congestion from
right-sided heart failure creates hepatic dysfunction (5),
malnutrition, and inflammatory stimulation, and is implicated in the cardio-renal syndrome, which heralds further
congestion and decline (6). Therefore, astute assessment and
intervention to treat congestion are vital to relieving patient
symptoms, enhancing quality of life, and improving prognosis, leading to a class I recommendation for both acute
and chronic management of heart failure (7).
See pages 15 and 24
Clinical signs of elevated filling pressures can generally be
directly attributed to elevated left- or right-sided heart
pressures. Because the concordance between elevated rightand left-sided filling pressures is 75% to 80% in chronic heart
failure (8,9), the signs and symptoms from right and left are
often congruent. For instance, Drazner et al. (10) have shown
previously that the most reliable sign of elevated left-sided
filling pressures is the right-sided sign of elevated jugular
venous pressure (JVP). Conversely, the most useful symptom
*Editorials published in the Journal of the American College of Cardiology: Heart Failure
reflect the views of the author and do not necessarily reflect the views of JACC: Heart
Failure or the American College of Cardiology.
From the Cardiovascular Division, Brigham and Women’s Hospital, Boston,
Massachusetts. Dr. Nohria has served as a consultant for Vertex Pharmaceuticals; and
as an investigator for St. Jude Medical. Dr. Stevenson is supported for training clinical
investigators by the National Heart, Lung, and Blood Institute (U01 HL084877).
Vol. 2, No. 1, 2014
ISSN 2213-1779/$36.00
http://dx.doi.org/10.1016/j.jchf.2013.12.001
for elevated left-sided pressures is orthopnea, which in
a patient with a history of heart failure should be considered
due to cardiac congestion unless otherwise explained.
Accordingly, in the ESCAPE (Evaluation Study of
Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial, orthopnea predicted a pulmonary
capillary wedge pressure >22 mm Hg. Peripheral edema
suggests elevated right-sided heart pressures but is less specific and less sensitive than JVP for elevated left-sided filling
pressures. Edema is generally absent in young patients with
severely elevated filling pressures, who may instead have
ascites, whereas edema often occurs in elderly patients, in
whom it is related to peripheral factors in the absence of
elevated central venous pressures. Symptoms of abdominal
discomfort, anorexia, and early satiety are associated more
specifically with elevated right-sided filling pressures (11).
A new symptom. Clinical assessment remains crucial for
the diagnosis and triage of heart failure. This assertion is
particularly true when evaluating for decompensation in a
patient who has a history of heart failure, which accounts for
approximately 80% of heart failure–related hospitalizations.
The study by Thibodeau et al. (12) in this issue of the
Journal proposes a new item to the classic litany of heart
failure symptoms: “bendopnea,” which is shortness of breath
or uncomfortable head fullness within 30 s of bending forward while sitting, such as to put on shoes or stockings. This
symptom was also described recently as “flexo-dyspnea,”
which was associated with an increase in echocardiographic
indices of left-sided filling pressures (13). In the study
by Thibodeau et al., invasive hemodynamic monitoring
demonstrated that bending forward increased venous return
and filling pressures, provoking shortness of breath, usually
in those patients who had baseline elevated filling pressures
and were thus more likely to reach the threshold pressures
needed to elicit symptoms. Patients with bendopnea also
had a higher body mass index, which may have aggravated
their discomfort when bending.
Each symptom we can elicit helps to complete the clinical
picture, as there is marked heterogeneity between patients
regarding their perception of symptoms. We have all
encountered patients who endorse 1 symptom but deny
another. It is particularly useful to know that bendopnea
correlates with elevated right-sided filling pressures. As facility with the jugular venous examination regrettably declines, recognition of bendopnea may help alert clinicians to
the likely elevation of right-sided pressures.
A portfolio of symptoms is helpful for longitudinal
tracking as well. Although there is marked variability between patients in presentation, individual patients tend to
have typical early warning signs as congestion occurs. For
some patients, difficulty putting on their shoes may alert
them to the need to re-evaluate their volume status and
diuretic regimen. It is also possible that a symptom such as
bendopnea could be used as a simple provocative bedside
test to identify patients with elevated filling pressures in the
absence of other signs or symptoms of congestion, much as
JACC: Heart Failure Vol. 2, No. 1, 2014
February 2014:32–4
careful observation during the supine physical examination
will sometimes reveal increased respiratory rate in a patient
unaware of orthopnea until asked.
Validation of clinical signs for prognosis. The physical
examination has been consistently shown to have prognostic
value in heart failure assessments. A post-hoc analysis of the
SOLVD (Studies Of Left Ventricular Dysfunction) treatment trial found that an elevated JVP and an audible third
heart sound were each associated with an increased risk of
death and hospitalization for heart failure (14). Similarly,
bedside hemodynamic profiles based on physical examination findings of congestion and inadequate perfusion
predicted 1-year mortality and the need for urgent transplantation in patients with heart failure (1). These findings
were further supported by an analysis of the ESCAPE trial,
in which patients discharged with a “wet” or “cold” profile
had a 50% increased risk of death or rehospitalization
compared with those with a “dry” or “warm” profile (10).
A reassessment of signs and symptoms of heart failure at
1 month after hospital discharge provides further refinement
of prognosis, particularly if orthopnea has recurred (15).
In this issue of the Journal, Caldentey et al. (16) conducted a post-hoc analysis of patients enrolled in the AFCHF (Atrial Fibrillation and Congestive Heart Failure)
trial to evaluate the prognostic value of baseline physical
examination findings, including elevated JVP, third heart
sound, rales, and peripheral edema, in patients with systolic
heart failure. These authors confirmed that physical evidence
of congestion, defined by any of the 4 physical findings, is
associated with increased mortality and heart failure–related
hospitalizations. Although a multivariate analysis was performed, the elevated right- and left-sided heart filling
pressures are so strongly aligned that the contribution of
related signs cannot be isolated. Furthermore, unlike diagnostic or prognostic tests that require additional resources,
there is no need for artificial restriction of the clinical
assessment. The components of the assessment are easily
collected and drawn into a composite picture that conveys
more than just the theoretical risk of death or
hospitalization.
Does the clinical picture still matter? In an era in which
chemical biomarkers and imaging characterization of the
heart and hemodynamics are becoming increasingly focused
and refined, does the clinical picture still matter? As long as
our assessment goals remain the diagnosis, prognosis, and
treatment of heart failure, the symptoms and signs will
remain highly relevant.
To diagnose heart failure. Although supermarket screening
could increase the diagnosed prevalence of disease, we will
continue to elicit the symptoms and physical signs of heart
failure to establish and prioritize diagnoses as patients present with their “chief complaints.” As the population accumulates comorbidities with age, such assessment is even more
crucial to determine the relative contribution of each comorbidity to functional limitation. Biomarkers have been particularly helpful in raising awareness about heart failure as
Nohria and Stevenson
Observation Is Never Obsolete
33
a possible new diagnosis in the setting of dyspnea. However, in
the chronic management of patients with a known diagnosis
of heart failure, most clinical assessments are performed to
determine instead the level of compensation/decompensation
and the response to interventions.
To predict outcomes in heart failure. Individual biomarkers such as the natriuretic peptides have been very
strong predictors of outcome. This is true ranging from
asymptomatic to end-stage disease. As a potential alert to
more serious disease, biomarkers can be used to define trial
populations for newer therapies, patients in whom diseaseexchanging therapies such as mechanical circulatory assist
devices may be considered, and those for whom a discussion
of the goals of care should be initiated. However, the clinical
portrait of class IV heart failure, drawn from signs and
symptoms of congestion at rest or on minimal exertion,
remains 1 of the most vivid and robust predictors of poor
outcome. The components of this assessment as refined in
the 2 accompanying studies (12,16) further enhance this
portrait.
To guide therapy for heart failure. A target for treatment
must be clinically relevant, must respond to the therapies
given, and must change quickly and consistently enough to
guide serial intervention. The use of biomarkers to guide
therapy remains controversial. Using absolute levels of
natriuretic peptides as targets has encouraged more vigorous
up-titration of guideline-recommended therapies that do
not, however, achieve the biomarker targets in most patients
(17). Using individualized targets based on hospital
discharge levels led to the same interventions as those guided
by using clinical assessment (18).
There is undeniable face validity in treatment based on
signs and symptoms of heart failure. It is these signs and
symptoms that make the patients feel and look sick to those
who care for them. Even the patients’ preferences to trade
survival for comfort can be closely linked to elevated JVP and
the overall burden of heart failure symptoms (19,20).
Relieving the signs and symptoms of heart failure treats not
only the diagnosis but also the patient.
Support for the arts. It is encouraging to see these 2
studies sustain a focus on clinical assessment in heart failure,
in contrasting settings. The value of physical signs has been
noted in large trials focused on the therapy of heart failure,
but it is commendable that the physical examination was
performed in 1,376 patients with such rigor to confirm its
importance in the large AF-CHF trial focused on strategies
for atrial fibrillation (16). The legendary caliber of the Canadian cardiovascular training is upheld by the investigators
in this trial.
At the other end of the spectrum, a detailed study of 102
subjects in a dedicated advanced heart disease program illustrates how the care of each patient continues to provide
new insight for the observant (12). The physiological study
of the phenomenon of bendopnea encourages perpetual
curiosity to discover what makes patients feel sick and what
makes them feel better. Far beyond enumeration of
34
JACC: Heart Failure Vol. 2, No. 1, 2014
February 2014:32–4
Nohria and Stevenson
Observation Is Never Obsolete
components for billing codes, thoughtful elicitation of the
signs and symptoms of heart failure can be trusted to
strengthen the transcendent link between patient and
physician. Even when our patients cannot be cured, listening
may help us render them able to put on their own shoes
again.
9.
10.
11.
Reprint requests and correspondence: Dr. Anju Nohria,
Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis
Street, Boston, Massachusetts 02115. E-mail: [email protected].
12.
13.
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Key Words: atrial fibrillation - dyspnea - heart failure
hemodynamics - outcomes - physical examination.
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