Routine Physical Exams Insufficient to Diagnose Pulmonary Hypertension

Normal physical examinations do not demonstrate sufficient diagnostic power for pulmonary hypertension (PH), according to a study published in CHEST. Physical examinations should not serve as a threshold for ruling out PH, although a high jugular venous pulsation, right ventricular heave, and peripheral edema suggest acute PH.

This study included 116 participants being treated with right heart catheterization. Blinded examinations were performed by a medical student, a medical resident, and an attending physician, with calculations of positive and negative likelihood ratios, sensitivity, and specificity performed for each finding and grouped by type of examiner. Linear regression was used to compare right atrial pressure and jugular venous pulsation. Multivariate and univariate logistic regression were used to examine the association between physical findings and PH (mean pulmonary arterial pressure ≥25 mm Hg) or acutely elevated mean pulmonary arterial pressure (≥45 mm Hg).

In individuals undergoing right heart catheterization, PH had an 87% prevalence. PH was successfully indicated only by pulmonic regurgitation murmur (100% specificity;95% CI, 79%-100%) and jugular venous pulsation >3 cm (positive likelihood ratio, 2.5; 95% CI, 1.2-5.4). PH could be ruled out with some confidence with the absence of jugular venous pulsation >3 cm (negative likelihood ratio, 0.41; 95% CI, 0.27-0.63) and loud pulmonic component of the second heart sound (negative likelihood ratio, 0.49; 95% CI, 0.25-0.94).

There was an association between jugular venous pulsation and right atrial pressure (r=0.59; P <.001); however, this association resulted in underestimated right atrial pressure, with a mean bias of –3.4 cmH₂O (95% limits of agreement, –14.0 to 7.2). In multivariate analysis, PH could also be identified with the presence of a parasternal heave and jugular venous pulsation >3 cm (area under the curve, 0.75). Acute PH could be discriminated with a combination of peripheral edema, right ventricular heave, and jugular venous pulsation >3 cm (area under the curve, 0.82), yielding a 100% probability of acute PH.

Limitations to this study included a potential lack of generalizability due to the high prevalence of PH as well as physicians’ possible bias when diagnosing participants.

The study researchers concluded that “[t]he classic physical examination features associated with PH had low to modest diagnostic utility in this large cohort of patients referred for [right heart catheterization]. …[C]linicians should place low weight on the physical examination to exclude PH and should have a low threshold for further testing including echocardiography and right heart catheterization. Nevertheless, the presence of peripheral edema, [right ventricular] heave and a high [jugular venous pulsation] highly suggest the presence of severely elevated pulmonary artery pressure, which should prompt urgent diagnostic evaluation.”

Disclosures: Several authors report associations with pharmaceutical companies. For a full list of author disclosures, please visit the reference.

Reference

Braganza M, Shaw J, Solverson K, et al. A prospective evaluation of the diagnostic accuracy of the physical examination for pulmonary hypertension [published online March 1, 2019]. CHEST. doi:10.1016/j.chest.2019.01.035