Researchers Still Debating the Value of Physical Examination in Pulmonary Hypertension Diagnosis

Researchers Still Debating the Value of Physical Examination in Pulmonary Hypertension Diagnosis

Physical ExaminationA recent study entitled “Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study” evaluating the relevance of physical examination in diagnosing pulmonary hypertension was published in PlosOne by Rebecca Colman from Dr. John Granton’s Pulmonary Hypertension research group at Toronto General Hospital in Canada.

Pulmonary hypertension (PH) is a progressive disease characterized by augmentation of pulmonary vascular resistance that results in decreased right-heart function due to increased right ventricular after load, which is the pressure that the chambers of the heart must generate in order to eject blood. PH occurs mostly in young and middle-aged women, and the mean survival time from the onset of symptoms is approximately 2 to 3 years. The origin of PH is not well understood, though on average 10% of cases are due to familial disease, suggesting a genetic susceptibility.

Patients with pulmonary hypertension show a variety of physical manifestations reflecting  a volume and/or pressure overloaded right ventricle (RV), and many reports have described these signs during physical examination of patients, but there is no agreement about their diagnostic value. There are other tools and methods to validate the physical examination in the diagnosis of pulmonary hypertension, such as phonocardiography, 2-dimensional and Doppler echocardiography, but are not practical for most clinicians, and the majority continues to use the physical examination as the standard method although its scientific validation as a diagnostic tool for PH in symptomatic patient has not been assessed.

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In this study, the research team evaluated the diagnostic value of the physical examination in PH through literature review and an experimental study. The researchers methodically reviewed and evaluated the published literature using MEDLINE (from 1946 to Feb 2013) and EMBASE (from 1947 to March 22, 2013) on the physical examination in PH. Additionally, they evaluated the diagnostic value of the many physical signs of PH described in the literature by association with results of right heart catheterization (RHC). They also addressed the impact of the observer experience (specialist versus generalist) on the detection of signs during physical examination of patients that performed right heart cardiac catheterization, using as examiners 6 academic staff physicians, including three “experts” and three “generalists.” These patients were divided into two groups: patients with PH (with a mean pulmonary artery pressure (mPAP) >25 mmHg) and patients with normal pulmonary artery pressures (mPAP ≤25 mmHg).

In conclusion, the researchers found that the literature available consisted mainly of heterogeneous, small, cross-sectional and retrospective studies with many flaws in the selection of patients and the design of the study, leading to the overestimation of the relevance of physical examination findings. Thus it was not possible to draw conclusions from the published studies to support or exclude the physical examination as diagnostic tool for pulmonary hypertension. Moreover, the researchers found that “specialists” performed a little better than “generalists” in the use of physical examination. Finally, the absence of results is not enough to exclude the diagnosis of PH.

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