Document Detail

Bedside assessment of cardiac hemodynamics: the impact of noninvasive testing and examiner experience.
MedLine Citation:
PMID:  21944161     Owner:  NLM     Status:  MEDLINE    
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.
Aaron M From; Carolyn S P Lam; Sridevi R Pitta; Prasanna Venkatesh Kumar; Kais A Balbissi; Jeffrey D Booker; Inder M Singh; Paul Sorajja; Guy S Reeder; Barry A Borlaug
Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't     Date:  2011-09-22
Journal Detail:
Title:  The American journal of medicine     Volume:  124     ISSN:  1555-7162     ISO Abbreviation:  Am. J. Med.     Publication Date:  2011 Nov 
Date Detail:
Created Date:  2011-10-24     Completed Date:  2011-12-12     Revised Date:  2012-09-26    
Medline Journal Info:
Nlm Unique ID:  0267200     Medline TA:  Am J Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1051-7     Citation Subset:  AIM; IM    
Copyright Information:
Copyright © 2011 Elsevier Inc. All rights reserved.
Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
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MeSH Terms
Aged, 80 and over
Atrial Function, Right / physiology*
Echocardiography / methods*
Heart Catheterization
Heart Failure / diagnosis*,  physiopathology
Hemodynamics / physiology*
Middle Aged
Natriuretic Peptide, Brain / blood*
Observer Variation
Peptide Fragments / blood*
Physical Examination
Point-of-Care Systems*
Predictive Value of Tests
Prospective Studies
Pulmonary Wedge Pressure / physiology*
Venous Pressure / physiology*
Ventricular Dysfunction, Left / diagnosis,  physiopathology
Ventricular Dysfunction, Right / diagnosis,  physiopathology
Reg. No./Substance:
0/Peptide Fragments; 0/pro-brain natriuretic peptide (1-76); 114471-18-0/Natriuretic Peptide, Brain
Comment In:
Am J Med. 2012 Aug;125(8):e13; author reply e15-6   [PMID:  22840672 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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