Physical Exam Still Key in Predicting Deaths in Heart Failure with AF

Marlene Busko

January 08, 2014

MONTREAL, QC — A study of a modern cohort of patients with chronic heart failure and atrial fibrillation (AF) suggests that four signs of congestion on physical examination—peripheral edema, jugular venous distension, a third heart sound, and pulmonary rales—offer useful prognostic information beyond that obtained from standard clinical, ECG, or echo parameters[1].

In this retrospective study of patients in the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial, each sign of congestion was associated with an increased risk of cardiovascular mortality, all-cause mortality, and heart-failure–related death over a mean follow-up of 37 months.

The study "reinforces the importance of doing physical examinations, especially in the presence of congestive signs," senior author Dr Anique Ducharme (Montreal Heart Institute, Montreal, Quebec) told heartwire .

The message for clinicians is: "We should keep on looking for congestion in our patients, because in 2014 it still carries an important prognostic factor," she said. Peripheral edema, which is easy to assess, appears to be a better predictor of mortality than jugular venous distension, she observed.

The study was published online January 8, 2014 in JACC: Heart Failure.

Old Prognostic Tool in a Modern Era

"The value of a careful and thorough physical examination [for patients with heart failure] has come into question in an age when detailed imaging studies and ancillary testing are readily available" and provide a wealth of information, Ducharme and colleagues write.

A retrospective analysis published in 2001 and based on data from 25 years ago from the Studies of Left Ventricular Dysfunction (SOLVD) trial reported that jugular venous distension and a third heart sound were associated with increased cardiovascular mortality, as reported by heartwire , but that study did not look at peripheral edema or rales.

The prognostic value of a physical examination has not been examined in a modern cohort of patients with heart failure who are receiving currently recommended pharmacological management or in patients with AF, the researchers write.

Data from the AF-CHF trial provided "a good opportunity to see whether what we teach [cardiology] fellows to do—a thorough physical examination—is still important," Ducharme said.

Between May 2001 and June 2005, the AF-CHF trial enrolled 1376 patients who had symptomatic left ventricular systolic dysfunction and a history of nonpermanent AF and randomized them to rhythm- or rate-control treatments for AF. The patients had a mean age of 67 years, and 81% were male.

Most patients received ACE inhibitors (86%) or beta-blockers (79%), and almost half received aldosterone antagonists (45%).

All patients underwent echocardiography, but the trial did not measure levels of brain natriuretic peptide (BNP), Ducharme explained. Cardiologist site investigators performed the baseline physical examinations.

Almost a third of patients had peripheral edema (30.9%), and fewer patients had jugular venous distension (21.6%) or a third heart sound (15.0%) or pulmonary rales (12.9%).

All four signs were associated with cardiovascular mortality in univariate analyses.

After standard clinical, electrocardiographic, and echocardiographic measures were accounted for, in multivariate analyses:

  • Peripheral edema and pulmonary rales were still independent predictors of all-cause and cardiovascular mortality and were linked with a twofold greater risk of heart failure-related death.

  • Pulmonary rales independently predicted hospitalization for heart failure.

  • Jugular venous distension was associated with a 48% increased risk of heart-failure–related death.

  • A third heart sound did not independently predict any cardiovascular outcome.

The results may not be generalizable to pediatric patients or patients without AF, but they do suggest that a physical examination should not be overlooked for patients with heart failure, Ducharme concluded. "It provided information beyond what you see in echo and all the other tests that were done; even better, it's free," she noted.

The Atrial Fibrillation and Chronic Heart Failure Trial was funded by the Canadian Institutes of Health Research. Ducharme holds a senior research grant from the Fond de Recherche du Québec en Santé. Disclosures for the coauthors are listed in the paper.

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