ABC | Volume 110, Nº3, March 2018

Original Article Almeida Junior et al BNP, echo and clinical evaluation in heart failure Arq Bras Cardiol. 2018; 110(3):270-277 Figure 1 – Correlation between left atrial pressure (LAP) and B-type natriuretic peptide (BNP). r = 0.3 (p = 0.046). 35 30 25 20 15 10 5 0 0 1000 2000 3000 4000 5000 BNP LAP Table 3 – Diagnostic characteristics of clinical signs to predict left atrial pressure ≥ 15 mm Hg Sensitivity Specificity PPV NPV Accuracy S3 44 55 79 20 46 PJVD 20 88 87 22 34 HJR 29 77 83 22 39 Edema 29 77 83 22 39 Hepatomegaly 29 77 83 22 39 Rales 61 33 77 18 55 S3: third heart sound; PJVD: pathologic jugular venous distension; HJR: hepatojugular reflux, PPV: positive predictive value, NPV: negative predictive value. Discussion In this study, we have assessed the diagnostic accuracy of heart failure clinical signs to predict elevation of cardiac filling pressures as derived from echocardiogram-based parameters. Additionally, we have combined information from clinical signs and chest radiography regarding congestion and finally added the BNP value in order to augment the diagnostic accuracy in assessing congestion. This strategy reflects a “real world” practice to clinically evaluate the hemodynamics of ADHF patients, and we compared this clinical approach with objective measurements of hemodynamics derived from tissue Doppler echocardiogram. We have shown that a CS of congestion, chest radiography and BNP, alone or in combination do not accurately predict elevation of LAP. Clinical findings in ADHF Jugular venous pressure The jugular venous pressure is the most important and probably the only physical examination sign that is relatively accurate in estimating ventricular filling pressures. 17 In a study with 35 patients in a critical care unit, the jugular venous pressure was accurate in estimating lowor high filling pressures. 18 In another study, after evaluating a thousand patients referred for cardiac transplantation, the authors observed that estimated right atrial pressure below or above 10 was concordant with a pulmonary capillary wedge pressure (PCWP) below or above 22 mm Hg in 79% of patients. 19 Other studies also have shown prognostic information about elevated jugular venous pressure in patients with heart failure. Its presence was associated with adverse outcome, including progression of heart failure, even after adjustment for other prognostic factors. 20 But several factors limit its power in predicting filling pressures. There is not a universal method to estimate the jugular venous pressure. Controversy exists regarding the position (sitting upright or semirecumbent position of 30-45°), the jugular vein being used (internal x external), and the technique of measurement (vertically above clavicle, Louis angle or estimated right atrium position). 21,22 In patients with heart failure with preserved systolic function, the jugular vein pressure is far less studied. 23,24 In accordance with these observations, we have also found that elevated jugular venous pressure had the best specificity (88%) of all physical findings for elevated LAP. Additionally, in patients with no elevated jugular venous pressure, but with a positive hepatojugular reflux, we were able to identify an elevated LAP in 10 out of 12 patients. However, as expected, the absence of elevated jugular venous pressure was not able to exclude elevated LAP. Third heart sound Collins et al. 25 have studied patients with dyspnea in the emergency department and found that S3 did not improve diagnostic accuracy for ADHF, with a sensitivity of only 14.6%. 273