Far from obsolete, physical examinations, patient history important for HF diagnosis

Despite advances in technology and technique, these are still critical for complete patient assessment.

Heart Failure Society of America 13th Annual Scientific Meeting

Using information from patient history and a clinical physical examination is an inexpensive and low-risk way of gathering important diagnostic and prognostic information for patients with HF.

Challenging the contention that the physical examination has become obsolete in an era of more complex technologies and detection methods such as biomarker evaluation and cardiac imaging, Mark H. Drazner, MD, a cardiologist and associate professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas, maintained that a routine physical examination and paying close attention to patient history provides as much essential information as more sophisticated diagnostic/prognostic tools.

“On a scale of worth, many people view more sophisticated technologies like biomarkers, imaging and implantable monitors as having more weight than the history and physical examination,” Drazner said in a presentation. “Yet, if you think about it, the majority of our decision-making on a day-to-day basis is based on the history and physical examination.”

Volume assessment, prognostic information

Some of the information provided by patient history and physical examination is critical, Drazner argued, and includes not only the assessment of volume status, but other prognostic information as well. Jugular venous pressure was cited as perhaps the most important marker of intravascular volume. Drazner noted that this information could be obtained during a physical examination by measuring the filling pressures of the neck veins, and that data from a study in which the researchers used an invasive catheter to gauge the correlative relationship between right and left side filling pressures ended up supporting the observations made during the noninvasive physical examination. Results from the ESCAPE study suggested that estimates of right atrial filling pressure during a physical examination prior to intervention correlated with similar observed pressures following the intervention. A similar correlation was observed when Drazner and colleagues examined left side filling pressures in another study.

“When you perform a history and physical examination, there are a large number of variables that you require, but you can boil this down to two simple parameters in the physical exam,” Drazner said. “If you want to estimate the volume status, determine if the neck veins are elevated or not, and determine if the patient has orthopnea or not.”

In addition to volume assessment, physical examinations also provide prognostic information useful in the assessment of patients with HF. Drazner presented data suggesting that simple BP measurement at patient entry could be a useful predictor of mortality. Data cited from the DIG trial suggested that the prognostic score of patients (using a number of variables detected during the physical examination like elevated jugular venous pressure, exercise limitations, dyspnea, edema and others) was an independent predictor of one-year and three-year mortality.

“The history and physical examination does allow us to risk-stratify patients, even with a simple measure of BP or whether neck veins are elevated or not,” Drazner said. “Certainly, as with every tool that assesses risk, composite measures are going to be better. As for the concept of static vs. dynamic measurements, the history and physical examination after therapy appear especially important.” – by Eric Raible

For more information:

Drazner M. Symposium XIV. Presented at: Heart Failure Society of America 13th Annual Scientific Meeting; September 13-16, 2009; Boston