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Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study

INTRODUCTION: Patients with pulmonary hypertension (PH) often present with a variety of physical findings reflecting a volume or pressure overloaded right ventricle (RV). However, there is no consensus regarding the diagnostic utility of the physical examination in PH. METHODS: We conducted a system...

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Autores principales: Colman, Rebecca, Whittingham, Heather, Tomlinson, George, Granton, John
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2014
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4208756/
https://www.ncbi.nlm.nih.gov/pubmed/25343585
http://dx.doi.org/10.1371/journal.pone.0108499
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author Colman, Rebecca
Whittingham, Heather
Tomlinson, George
Granton, John
author_facet Colman, Rebecca
Whittingham, Heather
Tomlinson, George
Granton, John
author_sort Colman, Rebecca
collection PubMed
description INTRODUCTION: Patients with pulmonary hypertension (PH) often present with a variety of physical findings reflecting a volume or pressure overloaded right ventricle (RV). However, there is no consensus regarding the diagnostic utility of the physical examination in PH. METHODS: We conducted a systematic review of publications that evaluated the clinical examination and diagnosis of PH using MEDLINE (1946–2013) and EMBASE (1947–2013). We also prospectively evaluated the diagnostic utility of the physical examination findings. Patients who underwent right cardiac catheterization for any reason were recruited. After informed consent, participants were examined by 6 physicians (3 “specialists” and 3 “generalists”) who were unaware of the results of the patient's hemodynamics. Each examiner independently assessed patients for the presence of a RV lift, loud P2, jugular venous distension (JVD), tricuspid insufficiency murmur and right-sided 4th heart sound at rest and during a slow inspiration. A global rating (scale of 1–5) of the likelihood that the patient had pulmonary hypertension was provided by each examiner. RESULTS: 31 articles that assessed the physical examination in PH were included in the final analysis. There was heterogeneity amongst the studies and many did not include control data. The sign most associated with PH in the literature was a loud pulmonic component of the second heart sound (P2). In our prospective study physical examination was performed on 52 subjects (25 met criteria for PH; mPAP ≥25 mmHg). The physical sign with the highest likelihood ratio (LR) was a loud P2 on inspiration with a LR +ve 1.9, 95% CrI [1.2, 3.1] when data from all examiners was analyzed together. Results from the specialist examiners had higher diagnostic utility; a loud P2 on inspiration was associated with a positive LR of 3.2, 95% CrI [1.5, 6.2] and a right sided S4 on inspiration had a LR +ve 4.7, 95% CI [1.0, 15.6]. No aspect of the physical exam, could consistently rule out PH (negative LRs 0.7–1.3). CONCLUSIONS: The presence of a loud P2 or audible right-sided 4th heart sound are associated with PH. However the physical examination is unreliable for determining the presence of PH.
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spelling pubmed-42087562014-10-27 Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study Colman, Rebecca Whittingham, Heather Tomlinson, George Granton, John PLoS One Research Article INTRODUCTION: Patients with pulmonary hypertension (PH) often present with a variety of physical findings reflecting a volume or pressure overloaded right ventricle (RV). However, there is no consensus regarding the diagnostic utility of the physical examination in PH. METHODS: We conducted a systematic review of publications that evaluated the clinical examination and diagnosis of PH using MEDLINE (1946–2013) and EMBASE (1947–2013). We also prospectively evaluated the diagnostic utility of the physical examination findings. Patients who underwent right cardiac catheterization for any reason were recruited. After informed consent, participants were examined by 6 physicians (3 “specialists” and 3 “generalists”) who were unaware of the results of the patient's hemodynamics. Each examiner independently assessed patients for the presence of a RV lift, loud P2, jugular venous distension (JVD), tricuspid insufficiency murmur and right-sided 4th heart sound at rest and during a slow inspiration. A global rating (scale of 1–5) of the likelihood that the patient had pulmonary hypertension was provided by each examiner. RESULTS: 31 articles that assessed the physical examination in PH were included in the final analysis. There was heterogeneity amongst the studies and many did not include control data. The sign most associated with PH in the literature was a loud pulmonic component of the second heart sound (P2). In our prospective study physical examination was performed on 52 subjects (25 met criteria for PH; mPAP ≥25 mmHg). The physical sign with the highest likelihood ratio (LR) was a loud P2 on inspiration with a LR +ve 1.9, 95% CrI [1.2, 3.1] when data from all examiners was analyzed together. Results from the specialist examiners had higher diagnostic utility; a loud P2 on inspiration was associated with a positive LR of 3.2, 95% CrI [1.5, 6.2] and a right sided S4 on inspiration had a LR +ve 4.7, 95% CI [1.0, 15.6]. No aspect of the physical exam, could consistently rule out PH (negative LRs 0.7–1.3). CONCLUSIONS: The presence of a loud P2 or audible right-sided 4th heart sound are associated with PH. However the physical examination is unreliable for determining the presence of PH. Public Library of Science 2014-10-24 /pmc/articles/PMC4208756/ /pubmed/25343585 http://dx.doi.org/10.1371/journal.pone.0108499 Text en © 2014 Colman et al http://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.
spellingShingle Research Article
Colman, Rebecca
Whittingham, Heather
Tomlinson, George
Granton, John
Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study
title Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study
title_full Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study
title_fullStr Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study
title_full_unstemmed Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study
title_short Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study
title_sort utility of the physical examination in detecting pulmonary hypertension. a mixed methods study
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4208756/
https://www.ncbi.nlm.nih.gov/pubmed/25343585
http://dx.doi.org/10.1371/journal.pone.0108499
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