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CardioNerds Amit Goal, Daniel Ambinder, & Dr. Alex Pipilas (FIT, Boston University)\xa0discuss the clinical examination in patients with heart failure with Dr. Mark Drazner, professor of medicine, clinical chief of cardiology, and medical director of the LVAD and Cardiac Transplantation Program at UT Southwestern. In this pearl laden episode, they discuss how the exam can be used to non-invasively assess a patient's hemodynamic status, risk stratify and inform prognosis, and guide management. They also discuss ways to master the evaluation of the JVP and categorize patients based on their RA:PCWP ratio. \n\n\n\nCheck out the CardioNerds Failure Heart Success Series Page for more heart success episodes and content!\n\n\n\nRelevant disclosures: None\n\n\n\n\n\nThe CardioNerds Heart Success Series is developed in collaboration with the Heart Failure Society of America. The Heart Failure Society of America is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.\n\n\n\n\n\n\n\n\n\n\n\n\n\nThis episode is made possible with support from Panacea Financial. Panacea Financial is a national digital bank built for doctors by doctors. Visit panaceafinancial.com today to open your free account and join the growing community of physicians nationwide who expect more from their bank. Panacea Financial is a division of Primis, member FDIC.\n\n\n\n\n\n\n\n\n\n\n\nPearls \u2022 Notes \u2022 References \u2022 Guest Profiles \u2022 Production Team\n\n\n\n\n\n\n\n\n\nCardioNerds Heart Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll\n\n\n\n\n\nCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!\n\n\n\n\n\n\n\n\n\nPearls - Clinical Examination in Heart Failure\n\n\n\nBegin hemodynamic assessment with the evaluation of congestion (\u201cwet\u201d vs \u201cdry\u201d) and perfusion (\u201ccold\u201d vs \u201cwarm\u201d). In a 2x2 table, this breaks patients into 4 broad hemodynamic profilesThe most sensitive markers of congestion (PCWP > 30) are JVP >12 with an OR of 4.6 and the presence of orthopnea with an OR of 3.6\u201cIf you are cold, you are cold, if you are warm, you can still be cold\u201d. Sensitivity for clinical markers of low cardiac index is very poor. Consider a low output state in patients with poor response to what are thought to be appropriate therapiesMost patients with acute on chronic heart failure have an RA:PCWP ratio of 1:2. These patients are the so called \u201cconcordant\u201d phenotype. There are two other sub-phenotypes:The \u201cRV equalizer group\u201d have an elevated RA:PCWP ratioThe \u201cRV compensated\u201d group have a lower RA:PCWP ratioClinical congestion at the time of hospital admission as well as discharge portends a poor prognosis for patients with heart failure\n\n\n\nShow notes - Clinical Examination in Heart Failure\n\n\n\n\n\n\n\nFigure 1\n\n\n\n1. What is the physical exam important in patients with heart failure?\n\n\n\nImportant to view the physical exam as a diagnostic test with strengths and limitationsIt is a noninvasive way to assess hemodynamics and risk stratify patientsCan provide information on prognosisMay enhance the provider-patient relationship\n\n\n\n2. How might we classify hemodynamics noninvasively?\n\n\n\nFramework begins with the \u201cStevenson\u201d Classification, developed by Dr. Lynne StevensonClassifies patients along two axes: congestion and perfusionCongestion is the assessment of overall volume status and estimation of right and left sided filling pressures, broadly broken up into \u201cwet\u201d or \u201cdry\u201d:\u201cWet\u201d, PCWP >15mmHg\u201cDry\u201d, PCWP <15mmHgPerfusion is the assessment of the adequacy of cardiac output to provide oxygen to peripheral tissues, broken up into \u201cwarm\u201d (i.e adequate perfusion) or \u201ccold\u201d (i.e poor perfusion):\u201cWarm\u201d, Cardiac index >2.2\u201cCold\u201d, Cardiac index <2.2You then develop a 2x2 table to begin hemodynamic assessment (Figure 1 - above)\n\n\n\n3.