Chakko S, Woska D, Martinez H, de Marchena E, Futterman L, Kessler K M, Myerberg R J
Department of Medicine, University of Miami School of Medicine, Jackson Memorial Hospital, Florida.
Am J Med. 1991 Mar;90(3):353-9. doi: 10.1016/0002-9343(91)80016-f.
Clinical and radiographic examinations are commonly used for estimating severity and titrating therapy of chronic congestive heart failure. The purpose of this study was to establish the relationship between findings on history, physical examination, chest roentgenogram, and pulmonary capillary wedge pressure (PCWP).
Fifty-two consecutive patients with chronic congestive heart failure, referred for evaluation for heart transplantation, were studied; all patients underwent history, physical examination, upright chest roentgenogram, and cardiac catheterization. The mean left ventricular ejection fraction was 0.19 +/- 0.06. Patients were divided into three groups according to their PCWP: Group 1, normal PCWP (less than or equal to 15 mm Hg, n = 19); Group 2, mild to moderately elevated PCWP (16 to 29 mm Hg, n = 15); Group 3, markedly elevated PCWP (greater than or equal to 30 mm Hg, n = 18).
Physical and radiographic signs of congestion were more common in the groups with higher PCWP, but they could not be used to reliably separate patients with different filling pressures. Physical findings (orthopnea, edema, rales, third heart sound, elevated jugular venous pressure) or radiographic signs (cardiomegaly, vascular redistribution, and interstitial and alveolar edema) had poor predictive value for identifying patients with PCWP values greater than or equal to 30 mm Hg. These findings had poor negative predictive value to exclude significantly elevated PCWP (greater than 20 mm Hg). Radiographic pulmonary congestion was absent in eight (53%) patients in Group 2 and seven (39%) in Group 3. In patients in Group 2 and 3, those without radiographic congestion were in a better New York Heart Association functional class (3.5 +/- 0.5 versus 2.8 +/- 0.6, p less than 0.01). There was good correlation between right atrial pressure and PCWP (r = 0.64, p less than 0.001). A normal right atrial pressure had no predictive value, but a pressure greater than 10 mm Hg was seen in all but one patient with a PCWP value greater than 20 mm Hg.
Clinical, radiographic, and hemodynamic evaluations of chronic congestive heart failure yield conflicting results. Absence of radiographic or physical signs of congestion does not ensure normal PCWP values and may lead to inaccurate diagnosis and inadequate therapy. It is not known whether therapy aimed at normalizing PCWP is superior to relieving clinical and radiographic signs of congestion.
临床和影像学检查常用于评估慢性充血性心力衰竭的严重程度并调整治疗方案。本研究的目的是确定病史、体格检查、胸部X线检查结果与肺毛细血管楔压（PCWP）之间的关系。
对52例因心脏移植评估而转诊的慢性充血性心力衰竭患者进行了研究；所有患者均接受了病史采集、体格检查、直立位胸部X线检查和心导管检查。平均左心室射血分数为0.19±0.06。根据PCWP将患者分为三组：第1组，PCWP正常（小于或等于15mmHg，n = 19）；第2组，PCWP轻度至中度升高（16至29mmHg，n = 15）；第3组，PCWP显著升高（大于或等于30mmHg，n = 18）。
PCWP较高的组中充血的体格和影像学体征更为常见，但它们不能可靠地用于区分不同充盈压的患者。体格检查结果（端坐呼吸、水肿、啰音、第三心音、颈静脉压升高）或影像学体征（心脏扩大、血管重新分布以及间质和肺泡水肿）对于识别PCWP值大于或等于30mmHg的患者预测价值较差。这些结果对于排除PCWP显著升高（大于20mmHg）的阴性预测价值也较差。第2组中有8例（53%）患者和第3组中有7例（39%）患者无影像学肺充血表现。在第2组和第3组患者中，无影像学充血表现的患者纽约心脏协会功能分级更好（3.5±0.5对2.8±0.6，p<0.01）。右心房压力与PCWP之间存在良好的相关性（r = 0.64，p<0.001）。正常右心房压力无预测价值，但在PCWP值大于20mmHg的患者中，除1例患者外，其余患者右心房压力均大于10mmHg。
慢性充血性心力衰竭的临床、影像学和血流动力学评估结果相互矛盾。无影像学或体格充血体征并不能确保PCWP值正常，可能导致诊断不准确和治疗不充分。目前尚不清楚旨在使PCWP正常化的治疗是否优于缓解临床和影像学充血体征的治疗。
