Hepatojugular Reflux

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.

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).

• Arterial flutter

• Arterial fibrillation

• Atrioventricular dissociation

• Cardiac tamponade

• Constructive pericarditis

• First-degree atrioventricular stroke

• Pulmonary hypertensmyxom

• Right atrial myxoma

• Tricuspid stenosis

• Tricuspid regurgitation

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.