Upsala J Med Sci 92: 287-292, 1987 Relations between Clinical Signs of Right and Left Cardiac Decompensation and Radiological Signs Thereof Christer Sylvkn, Ulf Hesser, Terje Ostby, UIrika Broom6 and Lars Zackrisson Departments of Internal Medicine and Radiology, Danderyd Hospital, Danderyd and Department of Radiology, S:t Gorans Hospital, Stockholm, Sweden ABSTRACT Ten consequtive patients arriving at the emergency department for severe systemic cardiac decompensation were investigated in res- pect of 17 clinical and laboratory parameters indicative of right or left heart failure. Investigations were made at arrival to the hospital and after completed in-hospital care. In respect of left heart failure the prescence of rales and signs of interstitial oedema had a similar-sensitivity. Both were of diagnostic value. Right heart failure was best diagnosed with clinical parameters such as pitting oedema, filling of the jugu- lar vein, and liver enlargement. The laboratory parameters were less sensitive and appeared to have not a diagnostic but well a confirmatory value. INTRODUCTION Clinical decision-making in cardiac decompensation both in res- pect of left and right ventricular failure is based on symptoms and signs.Pertinent findings are often verified by chest x-ray. This implies that chest x-ray is as sensitive or a more sensitive method and gives more reliable results than the clinical examina- tion. Ultra-sound scanning of the liver may be used to reveal signs of liver congestion. In fact Henriksson et a1 reported that the width of the major right hepatic vein was a reliable indica- tion of right heart failure. With the aim of evaluating the sensitivity of different parame- ters, an attempt was made to study changes in signs of left and right heart failure at clinical examination, at chest x-ray and at ultrasound investigation of the liver before and after therapy. 287 MATERIALS AND METHODS Ten consequtive patients arriving at the emergency department due to severe cardiac decompensation and systemic congestion were studied.The following clinical signs were recorded: Weight (kg) Pitting oedema: O=no oedema, l=ankle oedema, 2=leg oedema, but not above the knee and 3=oedema above the knee. Pulmonary rales: O=no rales, l=basal rales, Z=rales to the apex of the scapulae, 3=rales to the bases of the scapulae. Jugular vein(1): Its filling was estimated with the patient recumbent at a 30 degree position.More than 2 cm above the upper central edge of the manubrium sterni was estimated as pathologi- cal.The height of the filling (cm) was recorded. Kussmauls sign(2): The jugular vein was observed at inspiration. O=decreased filling, l=no change in filling, Zincreased filling. Hepatojugular reflux (3): A smooth but firm pressure was applied over the liver during 10 seconds.The jugular filling was obser- ved: O=no change in filling, l=increased distension of the jugu- lar vein but no increased filling in height, 2Zincreased filling in height which was estimated in cm when possible. - Liver: The following criteria was used to estimate dhether it was increased: palpable more than one finger below the right arcus. Palpable more than 40% of the distance between the apex of the processus xiphoidues and the umbilicus. In this location the li- ver is best palpated as no abdominal muscular tissue covers it. Based on these two estimates it was decided whether the liver was enlarged or not.O=liver size within the reference limit, l=enlar- ged, 2=painful liver at palpation. Chest x-ray: Films were taken in upright anterior-posterior and lateral views and when possible, lateral decubitus views for es- timation of pleural effusion. The films were then evaluated according to Milne et a1 for an estimation of vascular pedicle width (VPW) and v azygos width. VPW is formed by the leash of vessels extending from the thoracic inlet to the heart. Milne et a1 have shown that a change in VPW is closely correlated to the change in total blood volume and that the width of v azygos cor- relates with mean right atrial pressure. Heart size was estimated according in the upright position by routine methods. The presen- ce of redistribution of pulmonary blood flow, interstitial oede- ma, and Kerley B-lines were evaluated. 288 Ultrasound: The major right hepatic vein was measured in accor- dance to Henriksson et a1 , at the confluence with v.cava inferi- or. A Technicare Autosector 1, 3.5 mhz transducer was used. Statistics: Differences before and after treatment were tested by two-tailed paired Students t-test. RESULTS The age of the patients was 74+9 (58-89) years, 3 being female. Table 1 gives the results. In all patients treatment resulted in disappearence of pathological jugular filling, leg oedema and li- ver enlargement and a decrease in weight and heart size. Pleural effusion decreased in 7/10 and disappeared in 5/10 patients. He- patojugular reflux and an inspiratory increase of the jugular filling disappeared in about half of the patients.The per cent change was high and in the range of 80 to 85% for the jugular filling, leg oedema and liver score. In respect of the jugular filling changes were in the range of centimeters. Heart size and weight changed in the 10 per cent range. Interestingly, the de- crese in absolute heart size was more sensitive (higher P value) than the change in relative heart size. Sizes of the superior vena cava or the vascular pedicle and the azygos vein on chest x-ray were in the range of 28-43 mm, 63-78 mm and 7-16 mm, respectively. The major right hepatic vein as studied by ultrasound ranged between .6 and 18 =.These three vessels deacreased their size between 8 and 2 5 % with the highest change observed for the azygos vein. Compared to the upper refe- rence value for these vessels, the change was 40 to 100 per cent. Decreased size of the azygos vein was observed in all patients while the major right hepatic vein decreased only in 75% of the investigated patients. Rales and x-ray signs of interstitial oedema disappeared in all patients. Signs of redistribution remained in half of the pati- ents-Kerley lines when present disappeared with treatment. DISCUSSION Significant decreases were observed in all parameters tested (table 1). The significances were larger for the clinical compa- red to the x-ray and ultrasound parameters with the possible ex- ception of the width of the vena azygos. In respect of normality 289 Table 1. Meankstandard deviation of initial value or fraction of patients with an initial prescence of a diagnostic sign,per cent decrease, significance of the decrease (P-value) and the fracti’on of patients with decrease or normalisation of the 17 parameters rneasur ed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Initial % de- P-value Number of value crease patients Jugular filling, 4.8k2.2 cm Weight, 78217 kg Leg oedema, 1.950.9 score Liver , 1.610.5 Hepatojugular reflux, 1.010.5 Inspiratory jugular 1.320.7 f i 1 1 ing , Rales, 2.240.8 Heart size, ml absolute 162 12444 score score score score relative 8342141 Pleural effusion, 1.320.8 cm Vascular pedicle, 7529 m Superior vena cava, 3728 Azygos vein, 1223 Right hepatic vein, 10+4 mm mm mm Interstitial oedema 9/9 Kerley lines 5/9 Redistribution 10/10 a1 12 84 88 60 69 95 14 10 54 9 14 25 20 100 100 40 <0.0002