Revisiting a classical clinical sign: Jugular venous ultrasound

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Abstract

Background

Increased jugular venous pressure, reflecting the increased right atrial pressure, is a classical sign of heart failure (HF) but clinical assessment may be difficult.

Methods

In ambulatory patients with HF and control subjects, jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, during a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as diameter during Valsalva to that at rest.

Results

211 patients (mean age 70 years; mean left ventricular ejection fraction 43%) and 20 controls were included. JVD (median and inter-quartile [IQR] range) at rest was 0.17 (0.15–0.20) cm in controls and 0.23 (0.17–0.33) cm in patients with HF (p = 0.012), JVD ratio was 6.3 (4.3–6.8) in controls and 4.4 (2.7–5.8) in patients with HF (p = 0.001).With increasing quartiles of plasma NT-proBNP, JVD at rest rose (0.20 (0.15–0.23) cm, 0.21 (0.16–0.29) cm, 0.25 (0.18–0.35) cm and 0.34 (0.20–0.53) cm (P = < 0.001), whilst JVD ratio decreased (5.4 (4.2–6.4), 4.4 (3.5–6.3), 3.9 (2.4–5.4) and 2.8 (1.7–4.7); p = < 0.001). JVD ratio correlated with log (NT-proBNP) (r =  0.39, p = < 0.001), LV filling pressures (E/E′, r =  0.33, p = < 0.001) and left atrial volume (r =  0.21, p = 0.002). In a multivariable regression model, only trans-tricuspid gradient and TAPSE were independently associated with JVD ratio (R2 = 0.27).

Conclusions

Distension of the JV at rest relative to the maximum diameter during a Valsalva manoeuvre (JVD ratio) identifies patients with heart failure who have higher plasma NT-proBNP levels, right ventricular dysfunction and raised pulmonary artery pressure

Introduction

The clinical history and physical examination remain cornerstones in establishing a diagnosis of heart failure (HF), although objective tests are required for confirmation and to identify its likely aetiology.

Increased jugular vein (JV) distension, reflecting increased pressure in the right atrium [1] is one of the fundamental clinical signs of heart failure, which is also associated with an increased risk of hospitalization and death from heart failure [2].

Clinical estimates of right atrial pressure (RAP) using JV pressure (JVP) might often be accurate when assessed by experienced clinicians [3]. However, clinical estimation of JVP is often impossible or inaccurate and highly dependent on the observers' expertise, with only moderate agreement between those who are in medical training and their supervisors [4], [5] and may often underestimate right atrial pressure (RAP) [6]. Furthermore, it is difficult to make an objective measurement of JVP that can serve as a permanent record to share with other clinicians [7].

The JV is compliant and its size varies with changes in intravascular pressure and volume. Ultrasound provides a potential method of assessing and, importantly, recording JV distension and its response to physiological manoeuvres with precision [8], [9]. In this study, we sought to evaluate the respiratory variation of internal JV diameter measured using high frequency ultrasound to identify volume overload amongst patients with a spectrum of severity of heart failure and in control subjects without important myocardial or valve disease.

Section snippets

Study population

In 2011/2012, control subjects in sinus rhythm and patients with heart failure enrolled in the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF) [10], an international observational study of the prevalence, incidence and impact of key co-morbidities in out-patients with a clinical diagnosis of chronic heart failure who either had a left ventricular ejection fraction (LVEF) < 40% or a plasma concentration of amino-terminal pro-brain natriuretic peptide (NT-proBNP) > 400 ng/L

Patient characteristics

The mean (± standard deviation) age of patients with HF (n = 211, Table 1) was 70 + 10 years, 25% were women, 61% had IHD and 34% had AF (Table 1). Mean LVEF was 43 ± 12% and median plasma NTproBNP was 914 (IQR: 409 –2003) ng/l. Approximately 90% of patients were treated with beta-blockers and ACE-inhibitors and 62% were taking loop diuretics. Comparing patients with HF in the lowest and highest quartile of NTproBNP (Table 1), those in the highest quartile were older, had lower BMI, were more likely

Discussion

The JVP, unless there is superior vena cava obstruction, reflects RAP and is a useful measure of a patient's intravascular volume. However, estimation of pressure from the JVP suffers from high inter- (and probably intra-) observer variability [5], [12], has a large subjective component and is not easily recorded in an objective fashion that can be documented in a medical record and shown to colleagues [7]. If one doctor reports an elevated JV pressure and the following day another does not,

Conclusions

JV diameter (and its changes) can be assessed ultrasonically in most people and is associated with other measures of congestion, with pulmonary hypertension and RV dysfunction. It might be a useful bedside diagnostic test for patients with suspected heart failure or unexplained peripheral oedema. Hand-held echocardiography equipment might be helpful in more accurate estimation of patients' RA pressures and therefore dehydration/congestion and in stratifying prognosis in patients with heart

Acknowledgment

The research leading to these results has received funding from the European Union Seventh Framework Programme [FP7/2007–2013] under grant agreement n° 241558 (SICA-HF).

The research leading to these results has received funding from the Russian Ministry of Science and Education within the FTP “R&D in priority fields of the S&T complex of Russia 2007–2012” under state contract °02.527.11.0007.

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