Correspondence

Prognostic Importance of Elevated Jugular Venous Pressure and a Third Heart Sound in Patients with Heart Failure

N Engl J Med 2001; 345:1912-1913December 27, 2001

Article

To the Editor:

Drazner et al. (Aug. 23 issue)1 report the prognostic value of elevated jugular venous pressure and a third heart sound in patients with heart failure. Their review of data from the Studies of Left Ventricular Dysfunction trial2 indicates that the presence of one or both of these findings predicts an increased risk of death or hospitalization over a 32-month period, with relative risks ranging from 1.17 to 1.47. These numbers may be helpful when one is considering an entire population of patients with heart failure, but when I as a clinician am examining an individual patient, I need diagnostic tests that will help me discern who has a better or poorer prognosis.

When sensitivity and specificity are calculated and combined into likelihood ratios for the prediction of death from all causes or hospitalization for congestive heart failure, elevated jugular venous pressure has a positive likelihood ratio of only 1.67 and a negative likelihood ratio of 0.93. Similarly, for the prediction of death from all causes, a third heart sound has a positive likelihood ratio of only 1.27 and a negative likelihood ratio of 0.92, and the positive and negative likelihood ratios for the prediction of hospitalization for congestive heart failure are only 1.5 and 0.86.

Thus, when I examine an individual patient, the presence or absence of elevated jugular venous pressure or a third heart sound actually does very little to help me predict the likelihood of death or rehospitalization during the next three years. These findings may indicate the severity of heart failure at a given time, but the numbers reported by Drazner et al. indicate that they are not helpful for predicting long-term outcome.

William E. Cayley, Jr., M.D.
Eau Claire Family Medicine Clinic, Eau Claire, WI 54701
bcayley@yahoo.com

2 References

1. 1

   Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001;345:574-581
   Full Text | Web of Science | Medline

2. 2

   Studies of Left Ventricular Dysfunction (SOLVD) -- rationale, design and methods: two trials that evaluate the effect of enalapril in patients with reduced ejection fraction. Am J Cardiol 1990;66:315-322[Erratum, Am J Cardiol 1990;66:1026.]
   CrossRef | Web of Science | Medline

To the Editor:

Drazner et al. correctly conclude that in patients with heart failure, elevated jugular venous pressure and a third heart sound are each independently associated with adverse outcomes, including the progression of heart failure. Their article also illustrates the difference between significant association and prediction. For diagnostic procedures, prediction is often not better than the result of tossing a coin. Using the data given in Table 2 of the article by Drazner et al., I have calculated the positive and negative predictive values (Table 1Table 1Positive and Negative Predictive Values of Elevated Jugular Venous Pressure and a Third Heart Sound.). As expected, the more infrequent the event, the higher the negative predictive value. For the clinician faced with the individual patient, relevant positive predictive values are needed.

Hugo Ector, M.D., Ph.D.
University Hospital Gasthuisberg, B-3000, Leuven, Belgium
hugo.ector@med.kuleuven.ac.be

Author/Editor Response

The authors reply:

To the Editor: We appreciate the interest of Dr. Cayley and Dr. Ector in our study. Both question the predictive value of elevated jugular venous pressure or a third heart sound, despite the demonstrated significant association between these findings and adverse outcomes. Ector explores the predictive value of these physical-examination findings by calculating positive and negative predictive values, and Cayley does so by calculating likelihood ratios. Unfortunately, such calculations do not account for the time the end point was reached or for the differences in the length of follow-up between the patients with the physical-examination findings and those without the findings. Cox proportional-hazards models account for such considerations and thus are routinely used in the analysis of such data, as in our study.

We concur with Ector that there is a distinction between association and prediction in epidemiologic research. As others have stated,1 there is a need to develop prognostic tools to predict the risk of adverse outcomes for individual patients with heart failure. Methods to evaluate such prediction rules have been described,2 although the difficulties of achieving a clinically useful tool have recently been emphasized.3 In an individual patient with a complex illness such as heart failure, it is unlikely that any single measure alone — whether a physical-examination finding, a laboratory-test result, or an imaging study (e.g., echocardiogram) — will be sufficient for the accurate prediction of long-term outcome. However, according to the results of our study, physical-examination findings will probably be important components of such prediction rules. There is good reason to believe that elevated jugular venous pressure reflects elevated left-sided cardiac filling pressures in patients with chronic heart failure4; elevated left-sided cardiac filling pressures have been associated with an adverse prognosis in multiple studies. Because of the low cost of these assessments, the predictive value of repeated measurements (for example, of jugular venous pressure when it remains elevated despite diuretic therapy5) needs further exploration. We hope that such investigations will lead not only to more accurate prediction of adverse outcomes but also to improved allocation of therapies, a more important goal that will lead to improved outcomes.

Mark H. Drazner, M.D.
Daniel L. Dries, M.D., M.P.H.
University of Texas Southwestern Medical Center, Dallas, TX 75390-9034
mark.drazner@utsouthwestern.edu

Lynne W. Stevenson, M.D.
Brigham and Women's Hospital, Boston, MA 02115

5 References

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   Aaronson KD, Schwartz JS, Chen TM, Wong KL, Goin JE, Mancini DM. Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation. Circulation 1997;95:2660-2667
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   Wasson JH, Sox HC, Neff RK, Goldman L. Clinical prediction rules: applications and methodological standards. N Engl J Med 1985;313:793-799
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   Reynolds T. Prognostic models abound, but how useful are they? Ann Intern Med 2001;135:473-476
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   Drazner MH, Hamilton MA, Fonarow G, Creaser J, Flavell C, Stevenson LW. Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure. J Heart Lung Transplant 1999;18:1126-1132
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   Lucas C, Johnson W, Hamilton MA, et al. Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure. Am Heart J 2000;140:840-847
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Citing Articles (3)

Citing Articles

1. 1

   Daniel E. Forman. (2008) Heart failure in older adults. Current Cardiovascular Risk Reports 2:5, 390-397
   CrossRef

2. 2

   HUGO ECTOR. (2005) The Enigma of Statistics and Modern Cardiology. Pacing and Clinical Electrophysiology 28:4, 329-332
   CrossRef

3. 3

   Daniel E. Forman, Michael W. Rich. (2003) Heart Failure in the Elderly. Congestive Heart Failure 9:6, 311-323
   CrossRef