Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas.
Circ Heart Fail. 2021 Nov;14(11):e008779. doi: 10.1161/CIRCHEARTFAILURE.121.008779. Epub 2021 Sep 10.
In ≈25% of patients with heart failure and reduced left-ventricular ejection fraction, right-ventricular (RV), and left-ventricular (LV) filling pressures are discordant (ie, one is elevated while the other is not). Whether clinical assessment allows detection of this discordance is unknown. We sought to determine the agreement of clinically versus invasively determined patterns of ventricular congestion.
In 156 heart failure and reduced LV ejection fraction subjects undergoing invasive hemodynamic assessment, we categorized patterns of ventricular congestion (no congestion, RV only, LV only, or both) based on clinical findings of RV (jugular venous distention) or LV (hepatojugular reflux, orthopnea, or bendopnea) congestion. Agreement between clinically and invasively determined (RV congestion if right atrial pressure [RAP] ≥10 mm Hg and LV congestion if pulmonary capillary wedge pressure [PCWP] ≥22 mm Hg) categorizations was the primary end point.
The frequency of clinical patterns of congestion was: 51% no congestion, 24% both RV and LV, 21% LV only, and 4% RV only. Jugular venous distention had excellent discrimination for elevated RAP (C=0.88). However, agreement between clinical and invasive congestion patterns was poor, к=0.44 (95% CI, 0.34-0.55). While those with no clinical congestion usually had low RAP and PCWP (67/79, 85%), over one-half (24/38, 64%) with isolated LV clinical congestion had PCWP <22 mm Hg, most (5/7, 71%) with isolated RV clinical congestion had PCWP ≥22 mm Hg, and ≈one-third (10/32, 31%) with both RV and LV clinical congestion had elevated RAP but PCWP <22 mm Hg.
While clinical examination allows accurate detection of elevated RAP, it does not allow accurate detection of discordant RV and LV filling pressures.
在约 25%的心衰和左心室射血分数降低的患者中，右心室（RV）和左心室（LV）充盈压存在不一致（即一个升高而另一个不升高）。目前尚不清楚临床评估是否能发现这种不一致。我们旨在确定临床评估与侵入性确定心室充血模式的一致性。
在 156 例接受侵入性血流动力学评估的心衰和左心室射血分数降低患者中，我们根据 RV（颈静脉扩张）或 LV（肝颈静脉回流、端坐呼吸或弯下腰呼吸）充血的临床发现，对心室充血模式（无充血、仅 RV、仅 LV 或两者均有）进行分类。临床和侵入性确定（如果右心房压力[RAP]≥10mmHg 则为 RV 充血，如果肺毛细血管楔压[PCWP]≥22mmHg 则为 LV 充血）分类之间的一致性是主要终点。
充血的临床模式的频率为：51%无充血，24%同时存在 RV 和 LV 充血，21%仅 LV 充血，4%仅 RV 充血。颈静脉扩张对升高的 RAP 有很好的鉴别力（C=0.88）。然而，临床和侵入性充血模式之间的一致性较差，к=0.44（95%CI，0.34-0.55）。虽然没有临床充血的患者通常 RAP 和 PCWP 较低（67/79，85%），但超过一半（24/38，64%）孤立性 LV 临床充血的患者 PCWP<22mmHg，大多数（5/7，71%）孤立性 RV 临床充血的患者 PCWP≥22mmHg，约三分之一（10/32，31%）同时存在 RV 和 LV 临床充血的患者 RAP 升高但 PCWP<22mmHg。
虽然临床检查可以准确检测到升高的 RAP，但不能准确检测到不一致的 RV 和 LV 充盈压。
