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08/12/2011 - clinical exam in heart failure

posted Sep 20, 2011, 8:04 AM by Chief Resident   [ updated Sep 20, 2011, 8:05 AM by Purnema Madahar ]
The weekend has arrived and we completed our second week on the wards! Well done, everyone!

Once again I'd like to stress the need for thorough signouts and good communication over the weekend to ensure the best of care for our patients. Please call me if coverage instructions are not clear or if other problems arise. Interns, please turn to your sister team's resident for help if your resident is not around.

In resident report this morning, Robert Ostfeld reminded us of some great clinical findings in the exam of a patient with heart failure:

Q: Can you predict a low cardiac index by physical exam?
A: A proportional pulse pressure, i.e. (SBP-DBP):SBP < 25% can detect a cardiac index < 2.3 with 96% specificity.

Q: In decompensated chronic (not acute) heart failure, what percentage of patients don't have rales on exam?
A: 15%

These and many other validated characteristics of the physical exam can be found in a book all of you should have: Steven McGee 'Evidence Based Physical Diagnosis'; highly recommended!

Interestingly, the ESCAPE trial, which primarily investigated if  pulmonary artery catheter (PAC) guided treatment of decompensated CHF improved outcomes as compared to clinical assessment (it didn't) had a prespecified secondary objective: to determine the utility of skilled clinical assessment in advanced CHF. Data obtained by PAC was used as the gold standard. The paper is attached.