HEMODYNAMICS IN HEART FAILURE – IS CLINICAL EXAMINATION RELEVANT?

Abstract

Elucidating hemodynamic parameters remains the hallmark of management inpatients with acute or chronic heart failure. Demystification of assessment offilling pressures is a continual and vital pursuit for cardiologists. In the era ofhand-held imaging devices, extensive diastolic guidelines and readily availableemerging biomarkers ala, brain natriuretic peptide (BNP); is the role of clinicalexamination (CE) becoming obsolete? CE consists of carefully taken targetedhistory and meticulously conducted physical examination.

The determination of 'wet' is based on the presence of any sign or symptom that is associated with elevated ventricular fillingpressures. Assessing volume status is critical in the management of HF, helpful in titrating the dosage of diuretic and agentsused to modulate preload and afterload. Clinical findings that help to assess volume status are distention of jugular veins (JVD),hepatojugular reflux (HJR). Orthopnea, bendopnea and square-wave response of blood pressure during Valsalva maneuver.7Volume depletion can be detected by the presence of signs of dehydration, changes in blood pressure and heart rate withchanges in posture.7

A new term has been introduced in the world of cardiology called 'bendopnea' observed in patients with advanced HF. Patientsdevelop dyspnea on bending forward at the waist and it is assessed in patients while sitting in a chair and bending forwardtouching their feet with hands. It is deemed to be present if a patient develops dyspnea within 30 seconds of bending forward. 25 25Bendopnea was seen in a minority of patients with elevated filling pressure with low cardiac output. Recent studies have 26documented the presence of bendopnea in one fifth to half the number of patients presenting for evaluation for heart failure andits presence has been seen to increase worse outcomes in six months.26-29.

To conclude, meticulously conducted clinical examination is of immense importance in the management of patients with HF. Itoffers both diagnostic and prognostic information and is helpful in guiding the therapy. Clinical examination is more accurate inassessing elevated ventricular filling pressure inferred from signs of elevated right atrial pressure. Detection of low cardiacoutput remains challenging. In patients of HF with deteriorating renal function, low cardiac output and right-left equalizer of fillingpressure should be considered