Heart failure: physical signs helped to rule out.

Clinical bottom line (level 4)

  1. Nearly two thirds of patients with heart failure had positive physical signs.
  2. Patients with positive physical signs of heart failure were slightly more likely to have it (LR 1.39), and those with negative physical signs did not have it (LR 0 ).
  3. Patients with proportional pulse pressure = 25% were more likely to have heart failure (LR 5.44), and those with a pulse pressure >25% were slightly less likely to have it (LR 0).
  4. Patients with a cardiac index = 2.2 L/min/ ² were slightly more likely to have heart failure, (LR 1.64), and those with an index >2.2 did not have it (LR 0).
Stevenson and Perloff: Journal of the American Medical Association 1989; 261: 884-888
Expires October 2003

The study

Setting: cardiology department of a medical centre, USA

50 patients (aged mean 43 years, 74% male) heart failure accompanied by ventricular dilation and ejection fractions of = 0.30 (systolic dysfunction)
Therapy being taken at the time of the study included digoxin, vasodilators and milrinone.
?independent unblinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:
  • known heart failure;haemodynamic measurements of pulmonary capillary wedge pressure (>20 mmHg considered abnormal) and cardiac index (<2.2 L/min/m ³ considered abnormal)
Diagnostic test: physical signs- blood pressure using a sphygmomanometer and a stethoscope applied to the left or right brachial artery; pulmonary rales graded from 0 to 4, where a score of 1 indicates rales over on quarter of the posterior lung fields and 4 indicates rales over the entire posterior lung fields; central venous pressure assessed from internal and external jugular veins with the patient at 30 ° to 45 ° - graded as 0 if the crests of neither internal or external veins were visible above the clavicle and 4 if the crests were visible at the earlobe; peripheral oedema was graded 0 to 4 according to depth of indentation at ankle; third heart sounds were sought with a stethoscope; orthopnoea (during the previous week) was graded 0 to 4, with 0 indicating no need for more than one pillow on a flat bed and 4 indicating at least one night spent sleeping in a sitting position

The evidence


diagnostic test heart failure with high pulmonary wedge pressure (=22 mmHg); cardiac index =2.2 L/min/m² low wedge pressure (=18 mmHg) LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
physical examination 25 0 1.39
(1.09 to 1.77) 		58.0% 0.00
(0 to 42) 		0.00%
proportional pulse pressure, =25% or >25% (compared with cardiac index) 29 3 5.44
(1.92 to 15.4) 		91.0% 0.11
(0.04 to 0.34) 		17.0%
cardiac index, L/min/m² (=2.2 positive) compared with wedge pressure 32 0 1.64
(1.13 to 2.37) 		74.0% 0.00
(0 to 53) 		0.00%
total

Citation

  1. Stevenson LW, and Perloff JK: The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. Journal of the American Medical Association 1989; 261: 884-888
Contributor: Clare Wotton and Musab Hayatli, October 1999
Reviewer:

Clinical Question.
Patient chronic heart failure
Intervention or Exposure physical signs
Comparison haemodynamic measurements
Outcome diagnosis