Pulmonary Vascular Disease: Pulmonary Vascular Disease I |

Diagnostic Utility of the Physical Examination for Moderate and Severe Pulmonary Hypertension FREE TO VIEW

Daniel Vis; Kevin Solverson; Doug Helmersen; Jason Weatherald; Mitesh Thakrar; Rhea Varughese; Jeffrey Shaw; Michael Braganza; Naushad Hirani; Luke Rannelli
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University of Calgary, Calgary, AB, Canada

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1173A. doi:10.1016/j.chest.2016.08.1282
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SESSION TITLE: Pulmonary Vascular Disease I

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM

PURPOSE: Little is known about the utility of physical examination (PE) findings in evaluating patients with suspected moderate or severe pulmonary hypertension (PH) in the modern era. Our previous work has shown that PE is not adequate for excluding or confirming PH using the threshold of mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg. We aimed to determine the diagnostic utility of commonly referenced physical exam findings for detecting moderate-severe PH (mPAP ≥ 35 mmHg).

METHODS: Sequential patients undergoing right heart catheterization (RHC) at the PH clinic in Calgary, Canada were prospectively enrolled. A respirologist with PH experience examined each patient within 1 hour of RHC. Examiners were blinded to indication for RHC and diagnosis. Examiners determined presence or absence of physical examination signs: high jugular venous pressure (JVP) > 4cm, cV wave, palpable P2, parasternal heave, abdominal-jugular reflex (AJR), loud P2, P2 louder than A2 (P2>A2), right-sided S3, right-sided S4, pitting edema, tricuspid regurgitation and extra-physiologic splitting of S2. Examiner findings were compared to RHC to determine the sensitivity (Sn), specificity (Sp), positive (+LR) and negative likelihood ratio (-LR) with a threshold mPAP ≥ 35 to define moderate-to-severe PH.

RESULTS: 105 patients were enrolled. 66 were female with a median age of 61 (Interquartile Range 53-71). Median BMI 29.2 (Interquartile range 24.1-35.7). 69 patients (65.7 %) had moderate or severe PH (mPAP ≥ 35 mmHg). The diagnostic performances of PE findings are shown below. Examination Finding Sn (95%CI) Sp (95%CI) +LR(95%CI) -LR(95%CI) JVP>4cm 76 (64-85) 55 (38-72) 1.7 (1.2-2.6) 0.4 (0.2-0.7) cV wave 53 (40-66) 74 (56-87) 2.1 (1.1-3.8) 0.6 (0.5-0.9) Palpable P2 32 (22-46) 68 (51-83) 1.0 (0.6-1.9) 1.0 (0.7-1.3) Parasternal heave 45 (33-58) 74 (56-87) 1.8 (0.9-3.3) 0.7 (0.5-1.0) AJR 54 (41-67) 54 (37-71) 1.2 (0.8-1.8) 0.8 (0.6-1.3) Loud P2 86 (74-93) 31 (17-49) 1.3 (1.0-1.6) 0.4 (0.2-1.0) P2>A2 67 (54-78) 42 (27-60) 1.2 (0.8-1.6) 0.8 (0.5-1.3) R-sided S3 17 (9-29) 91 (75-98) 2.0 (0.6-6.7) 0.9 (0.8-1.1) R-sided S4 23 (14-36) 85 (69-95) 1.6 (0.7-4.1) 0.9 (0.7-1.1) Extra-physiologic Split S2 18 (10-31) 80 (63-91) 0.9 (0.4-2.2) 1.0 (0.8-1.2) Pitting Edema 47 (34-60) 77 (59-89) 2.1 (1.1-4.0) 0.7 (0.5-0.9) Tricuspid Regurgitation 51 (38-64) 63 (45-78) 1.4 (0.85-2.3) 0.8 (0.5-1.1).

CONCLUSIONS: A JVP of greater than or equal to 4 cm above the sternal angle, and a loud P2 appear to have reasonable sensitivity to detect the condition. Right-sided S3 and S4 appear to have reasonable specificity. However, overall the physical exam has limited diagnostic utility in detecting the presence of moderate-severe pulmonary hypertension. These results are in keeping with our prior work.

CLINICAL IMPLICATIONS: The physical exam for pulmonary hypertension alone, even when performed by respirologists with training in PH, has limited ability to identify patients with significantly elevated mean pulmonary artery pressures. This stresses the importance of alternative radiographic, biochemical and potentially invasive methods in combination with the physical exam in the work up and diagnosis of pulmonary hypertension.

DISCLOSURE: The following authors have nothing to disclose: Daniel Vis, Kevin Solverson, Doug Helmersen, Jason Weatherald, Mitesh Thakrar, Rhea Varughese, Jeffrey Shaw, Michael Braganza, Naushad Hirani, Luke Rannelli

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