Hepatojugular Reflux


Article Author:
Yash Vaidya


Article Editor:
Amit Dhamoon


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/30/2019 4:11:12 PM

Introduction

A detailed history and physical examination are cornerstones of diagnosing and managing congestive heart failure (CHF) for years. The evolution of non-invasive imaging over the past few decades has brought the accuracy of physical examination into question.[1],[2] Simple bedside physical exam maneuvers, such as the hepatojugular reflux (HJR), are valuable adjuncts that can aid in the diagnosis and management of CHF. In 1885, Pasteur first described the hepatojugular reflux as a physical sign of tricuspid regurgitation.

Etiology

Studies have correlated a positive hepatojugular reflux to multiple cardiac conditions. Some showed that hepatojugular reflux correlated best with left-sided heart failure,[3] while others demonstrate a stronger association with right-sided pressures.[4] A consistently significant relationship has been noted between a positive hepatojugular reflux and right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP), pulmonary artery systolic pressure (PASP), and pulmonary artery diastolic pressure (PADP), suggesting it could be a marker of both elevated left-sided and right-sided filling pressures.[5] Hence, hepatojugular reflux should not be considered diagnostic of any particular condition, but an indication that the right ventricle cannot accommodate an increased venous return. Constrictive pericarditis, right ventricular failure (commonly due to infarction), and restrictive cardiomyopathy are conditions that frequently produce a positive hepatojugular reflux. Left ventricular failure also produces this sign, but usually when the PCWP is more than 15 mmHg. Cardiac tamponade does not lead to a positive hepatojugular reflux.

Epidemiology

More than 25 million patients are affected by congestive heart failure (CHF) worldwide.[6] In the United States alone, there are 1 million hospitalizations attributed to CHF each year, with healthcare costs estimated to be close to $17 billion.[7] The morbidity and mortality rates of CHF remain significantly high, with a readmission rate crossing 50% in the first 6 months following discharge.[8],[9] The most common cause of readmission is volume overload, which at times is recognizable at the time of discharge despite adequate treatment. The hepatojugular reflux is a simple, non-invasive test that can diagnose volume overload in CHF patients at the bedside.

Pathophysiology

Deep inspiration generates negative intrathoracic pressure, leading to an increased venous return to the right atrium and, subsequently, the right ventricle. This phenomenon, in the healthy adult, enhances blood flow in the right heart chambers and causes decreased jugular venous pressure (JVP). It is by this mechanism that Carvallo noted that deep inspiration caused augmentation of right-sided heart murmurs, such as that of tricuspid regurgitation.[10] However, in patients with constrictive pericarditis or right ventricular failure, obstruction of flow in the right-sided chambers leads to increased JVP. This paradoxical rise in JVP was described in constrictive pericarditis by Kussmaul.

As noted by Pasteur, sustained abdominal pressure, similar to the mechanism described above, also causes an increased venous return. This forms the basis of the hepatojugular reflux, in which a sustained elevation of JVP on applying abdominal pressure is used as a marker of right ventricular failure.

History and Physical

The patient should be positioned in a manner that the jugular venous pressure can be easily seen. Classically, the patient is placed in a semi-recumbent position with an elevation of the head of the bed to 30 to 45 degrees. There should be at least a 3 cm margin from the upper margin of the baseline JVP to the angle of the mandible. A steady abdominal pressure of around 20 to 35 mmHg is then applied. Historically, the pressure was applied for 15 seconds.[11] However, recent evidence suggests JVP elevation for 10 seconds may be adequate.[12] The site of abdominal compression does not significantly alter the test. It is not mandatory to apply pressure directly onto the liver, as intra-abdominal pressure is increased even by midline pressure. The latter, in fact, may be preferable because direct pressure to the liver may be painful. Sustained elevation of JVP by more than 3 cm is considered a positive hepatojugular reflux. An elevation of 1 to 3 cm is considered normal. Clinicians who believe placing patients in this position is cumbersome and often produces inaccuracies recommend placing the patient upright at 90 degrees, which makes the clavicle approximately 10 cm above the right atrium. Any elevation of JVP above the clavicle is considered positive if sustained for more than 10 seconds.

Evaluation

A study evaluating data from the ESCAPE trial showed the importance of evaluating the hepatojugular reflux in patients admitted with heart failure.[5] The hepatojugular reflux is a simple bedside clinical sign with a high intraobserver agreement of around 97%, which highly correlated with signs of congestion on physical examination and brain natriuretic peptide. There was also a positive correlation with central parameters of volume overload: the pulmonary capillary wedge pressure and right atrial pressure.

Prior studies have shown the hepatojugular reflux to be very useful in dyspnea patients for predicting heart failure if the PCWP greater than or equal to 15 mmHg. Some studies have also noted a high specificity of about 96% for the hepatojugular reflux in diagnosing heart failure.[13] This study confirmed these findings. They also found that a positive hepatojugular reflux on discharge was determined by higher RAP, PASP, and PADP and was associated with a higher inferior vena cava diameter, which is an accurate determinant of patients’ volume status with the ability to predict decompensated heart failure.

The 6-month mortality of patients who had persistent hepatojugular reflux on discharge was significantly higher compared to those who had a resolution of hepatojugular reflux (univariate OR: 2.167; 95% CI: 1.189–3.949; ?? = 0.012). This study also assessed the role of combined assessment of positive hepatojugular reflux and jugular venous distention (defined as jugular venous pressure greater than 8 mmHg) in outcomes after discharge. Patients with positive hepatojugular reflux and jugular venous distention on discharge had a higher 6-month mortality compared with those with positive hepatojugular reflux and no jugular venous distention (33.8% versus 16.7%, resp.; univariate OR: 2.558; 95% CI: 1.023 to 6.397; ?? = 0.045).

Pearls and Other Issues

With the rapid advancements being made in diagnostic tools, including imaging or invasive tests, for detection of heart failure, there has been reduced emphasis on physical examination skills. The hepatojugular reflux is a very simple and useful bedside test that can diagnose right heart failure. Performance of the test has been described earlier in the manuscript. We encourage residents and physicians to routinely perform a detailed physical examination including hepatojugular reflux, which can help diagnose or rule out right heart failure.


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Hepatojugular Reflux - Questions

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On physical exam, which of the following conditions does not lead to a positive hepatojugular reflux?



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The hepatojugular reflux was first described as a physical sign of which condition?



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A patient is being examined at the bedside, and the hepatojugular reflux is elicited by placing the patient at 45 degrees and applying pressure over the abdomen. A sustained jugular venous pressure elevation of more than how many centimeters is considered a positive hepatojugular reflux?



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Hepatojugular reflux can be useful in assessing patients with dyspnea for predicting heart failure if the pulmonary capillary wedge pressure (PCWP) is which of the following?



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Hepatojugular Reflux - References

References

Mattleman SJ,Hakki AH,Iskandrian AS,Segal BL,Kane SA, Reliability of bedside evaluation in determining left ventricular function: correlation with left ventricular ejection fraction determined by radionuclide ventriculography. Journal of the American College of Cardiology. 1983 Feb     [PubMed]
Marantz PR,Tobin JN,Wassertheil-Smoller S,Steingart RM,Wexler JP,Budner N,Lense L,Wachspress J, The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation. 1988 Mar     [PubMed]
Ewy GA, The abdominojugular test: technique and hemodynamic correlates. Annals of internal medicine. 1988 Sep 15     [PubMed]
Sochowski RA,Dubbin JD,Naqvi SZ, Clinical and hemodynamic assessment of the hepatojugular reflux. The American journal of cardiology. 1990 Oct 15     [PubMed]
Omar HR,Guglin M, Clinical and Prognostic Significance of Positive Hepatojugular Reflux on Discharge in Acute Heart Failure: Insights from the ESCAPE Trial. BioMed research international. 2017     [PubMed]
Ambrosy AP,Fonarow GC,Butler J,Chioncel O,Greene SJ,Vaduganathan M,Nodari S,Lam CSP,Sato N,Shah AN,Gheorghiade M, The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. Journal of the American College of Cardiology. 2014 Apr 1     [PubMed]
Rosamond W,Flegal K,Furie K,Go A,Greenlund K,Haase N,Hailpern SM,Ho M,Howard V,Kissela B,Kittner S,Lloyd-Jones D,McDermott M,Meigs J,Moy C,Nichol G,O'Donnell C,Roger V,Sorlie P,Steinberger J,Thom T,Wilson M,Hong Y, Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008 Jan 29     [PubMed]
Krumholz HM,Merrill AR,Schone EM,Schreiner GC,Chen J,Bradley EH,Wang Y,Wang Y,Lin Z,Straube BM,Rapp MT,Normand SL,Drye EE, Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circulation. Cardiovascular quality and outcomes. 2009 Sep     [PubMed]
Joynt KE,Jha AK, Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives. Circulation. Cardiovascular quality and outcomes. 2011 Jan 1     [PubMed]
RIVERO CARVALLO JM, [Not Available]. Archivos del Instituto de Cardiologia de Mexico. 1946 Dec     [PubMed]
BURCH GE,RAY CT, Mechanism of the hepatojugular reflux test in congestive heart failure. American heart journal. 1954 Sep     [PubMed]
Ducas J,Magder S,McGregor M, Validity of the hepatojugular reflux as a clinical test for congestive heart failure. The American journal of cardiology. 1983 Dec 1     [PubMed]
Marantz PR,Kaplan MC,Alderman MH, Clinical diagnosis of congestive heart failure in patients with acute dyspnea. Chest. 1990 Apr     [PubMed]

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