MAHWASH SAEED, JACQUES RIZKALLAH, MEGAN JACK, LEIGH ANNE SHAFER, JAMES TAM Non Invasive Bedside Assessment of Right Atrial Pressure; Scanning into the Future

DISCLOSURES None.

RIGHT ATRIAL PRESSURE Noninvasive bedside physical examination of volume status is a common clinical skill taught to medical students early in their training Right atrial pressure ( RAP ) is used as a surrogate for central venous pressure and overall volume status

RAP: EVALUATION Noninvasive evaluation of RAP can be achieved by the following techniques: Jugular Venous Pressure ( JVP ) Peripheral Venous Collapse ( PVC ) Ultrasound visualization of the inferior vena cava ( IVC )

JVP: LIMITATIONS The JVP examination is a practical clinical tool, however it can be very difficult to assess in certain individuals obesity anomalous venous anatomy connective tissue diseases venous scarring from catheter insertion In such patients, alternative methods may be helpful, although not systematically validated

RAP ESTIMATION: ALTERNATIVE TECHNIQUES PVC, IVC collapse The relative accuracy of these techniques, compared to one another, and their application by trainees of varying experience remains uncertain

OBJECTIVES We compared the utility of the JVP, PVC, and bedside mini echo ( BME ) as non-invasive RAP clinical predictive tools amongst trainees of varying experience

METHODS A 2 nd year medical student, 2 nd year medical resident, and 2 nd year cardiology fellow examined patients presenting for outpatient and inpatient echocardiogram at a tertiary care hospital

METHODS Inclusion Criteria Patients receiving scheduled echo at St Boniface Hospital in Winnipeg, MB Patient able to give informed consent

METHODS Exclusion Criteria Patients with intravenous catheters (IV) or recent IV insertions within the last 2 weeks in the right arm or neck veins Patients with a history of intravenous drug use Patients who could not give informed consent, including those with language barrier

METHODS Patients were examined for JVP and PVC by all three examiners BME (without JVP/PVC) was utilized (after 10 hours of instruction) by the student in another group of patients Bedside RAP estimates were then compared to measurements from a complete echo study by a trained sonographer read by a level 3 echocardiologist

JVP

PERIPHERAL VEIN COLLAPSE

ANTHEM SIGN

BEDSIDE MINI ECHO

METHODS All patients underwent their regularly scheduled two dimensional echocardiographic examination The echo technologist and staff echocardiographer interpreting the study were not involved in the clinical assessment of the patients Assessment of the IVC by the echocardiographer was used as the gold standard for RAP estimates

Overall Patient Characteristics

SENSITIVITY OF PHYSICAL EXAM TECHNIQUES Examiner 1 MED STUDENT (N= 217) Examiner 2 MED RESIDENT (N= 58) Examiner 3 CARDIO FELLOW (N= 49) Examiner 1 BME (N= 43) P-Value Sensitivity for detecting increased CVP JVP PVC Anthem Sign BME 13% 15% 21% n/a 53% 8% 15% n/a 86% 50% 38% n/a 100% < n/a

PPV AND NPV OF SPECIFIC EXAM TECHNIQUES Examiner 1 MED STUDENT (N= 217 Examiner 2 MED RESIDENT (N= 58) Examiner 3 CARDIO FELLOW (N= 49) Examiner 1 BME (N= 43) PPV JVP PVC Anthem BME 39% 35% 39% n/a 47% 25% 29% n/a 44% 38% 50% n/a 40% NPV JVP PVC Anthem BME 75% 73% 74% n/a 75% 71% 72% n/a 91% 80% 78% n/a 100%

PPV AND NPV OF SPECIFIC EXAM TECHNIQUES IN OBESE PATIENTS (BMI >30)

RESULTS Of the physical exam maneuvers for detecting elevated RAP, the JVP was the most sensitive at 86% This improved with clinical experience

RESULTS The PVC/anthem sign more useful for the early learner who has not mastered the JVP yet There was consistency in the sensitivity of the anthem sign which hints towards ease of use and reproducibility

RESULTS The BME showed 100% sensitivity for detecting increased RAP

CONCLUSIONS The JVP was the most sensitive physical exam technique There may be an adjunctive role for the PVC and Anthem sign Helpful for early learner and in obese patients

CONCLUSIONS BME estimate of CVP is at least comparable to physical examination assessment and may require less instruction The use of BME in medical training should be further evaluated and encouraged

SCANNING INTO THE FUTURE…

ACKNOWLEDGEMENTS St Boniface Echo staff Photo models: Rosalie Grant Dr Anjala Chelvanathan Dr Ali Bagherli D Shelley Zieroth

ACKNOWLEDGEMENTS Dr Jacques Rizkallah Dr James Tam Megan Jack