title: Bedside assessment of cardiac hemodynamics: the impact of noninvasive testing and examiner experience.
abstract: BACKGROUND
  Knowledge of cardiac filling pressures is critical in the diagnosis and management of patients with dyspnea or heart failure. Echocardiography and B-natriuretic peptide (BNP) testing are commonly used to estimate these pressures, but their incremental value beyond physical examination remains unknown.
  
  
  METHODS
  Right and left heart filling pressures were prospectively estimated as "normal" or "abnormal" by staff cardiologists and cardiovascular trainees based upon physical examination findings alone, or examination coupled with echocardiographic and BNP data in patients referred for cardiac catheterization. Net reclassification improvement was calculated to determine whether echocardiographic/BNP data had incremental value in the determination of right and left heart pressures.
  
  
  RESULTS
  Two hundred fifteen observations were made by 9 examiners in 116 consecutive patients. Right and left heart pressures were accurately predicted from examination alone in 71% and 60% of observations, respectively. Examination-based accuracy was greater for staff cardiologists compared with trainees for right heart (82 vs 67%, P=.03) and left heart pressures (71% vs 55%, P=.03). Exposure to echocardiographic and BNP data did not enhance accuracy beyond bedside examination alone, both for left heart pressures (net reclassification improvement=-0.004; 95% confidence interval, -0.12-0.12) and right heart pressures (net reclassification improvement=0.02, 95% confidence interval, -0.09-0.13).
  
  
  CONCLUSIONS
  Cardiac filling pressures can be estimated from physical examination with modest accuracy, which is enhanced with experience. While echocardiographic and BNP data predict cardiac filling pressures, they may not provide information of incremental value beyond examination alone. Rigorous teaching and practice of cardiac examination skills should continue to be emphasized during medical training.
authors.affiliation: Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Aaron M
authors.initials: AM
authors.lastname: From
authors.forename: Carolyn S P
authors.initials: CS
authors.lastname: Lam
authors.forename: Sridevi R
authors.initials: SR
authors.lastname: Pitta
authors.forename: Prasanna Venkatesh
authors.initials: PV
authors.lastname: Kumar
authors.forename: Kais A
authors.initials: KA
authors.lastname: Balbissi
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Booker
authors.forename: Inder M
authors.initials: IM
authors.lastname: Singh
authors.forename: Paul
authors.initials: P
authors.lastname: Sorajja
authors.forename: Guy S
authors.initials: GS
authors.lastname: Reeder
authors.forename: Barry A
authors.initials: BA
authors.lastname: Borlaug
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016280:Atrial Function, Right / Q000502:physiology*; D006328:Cardiac Catheterization; D004452:Echocardiography / Q000379:methods*; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000503:physiopathology; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D015588:Observer Variation; D010446:Peptide Fragments / Q000097:blood*; D010808:Physical Examination; D019095:Point-of-Care Systems; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011669:Pulmonary Wedge Pressure / Q000502:physiology*; D014690:Venous Pressure / Q000502:physiology*; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000503:physiopathology; D018497:Ventricular Dysfunction, Right / Q000175:diagnosis / Q000503:physiopathology
chemical_list: D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain