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Fischer EA, Barajas R, Kalam KA, Rao SJ, Chou J, Calderon LM, Weisman DS. The Ultrasound Hepato-Jugular Reflux: Measuring the Hepato-Jugular Reflux with Ultrasound with Comparison to Invasive Right Heart Catheterization. Am J Med 2024; 137:545-551.e6. [PMID: 38401676 DOI: 10.1016/j.amjmed.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Ultrasound can overcome barriers to visualizing the internal jugular vein, allowing hepato-jugular reflux and jugular venous pressure measurement. We aimed to determine operating characteristics of the ultrasound hepato-jugular reflux and ultrasound jugular venous pressure predicting right atrial and pulmonary capillary occlusion pressures. METHODS In a prospective observational cohort at three US academic hospitals the hepato-jugular reflux and jugular venous pressure were measured with ultrasound before right heart catheterization. Receiver operating curves, likelihood ratios, and regression models were utilized to compare the ultrasound hepato-jugular reflux and ultrasound jugular venous pressure to the right atrial and pulmonary capillary occlusion pressures. RESULTS In 99 adults undergoing right heart catheterization, an ultrasound hepato-jugular reflux had a negative likelihood ratio of 0.4 if 0 cm and a positive likelihood ratio of 4.3 if ≥ 1.5 cm for predicting a pulmonary capillary occlusion pressure ≥ 15 mmHg. Regression modeling predicting pulmonary capillary occlusion pressure was not only improved by including the ultrasound hepato-jugular reflux (P < .001), it was the more impactful predictor compared with the ultrasound jugular venous pressure (adjusted odds ratio 2.6 vs 1.2). The ultrasound hepato-jugular reflux showed substantial agreement (kappa 0.76; 95% confidence interval, 0.30-1.21), with poor agreement for the ultrasound jugular venous pressure (kappa 0.11; 95% confidence interval, -0.37-0.58). CONCLUSION In patients undergoing right heart catheterization, the ultrasound hepato-jugular reflux is reproducible, has modest impact on the probability of a normal pulmonary capillary occlusion pressure when 0 cm, and more substantial impact on the probability of an elevated pulmonary capillary occlusion pressure when ≥ 1.5 cm.
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Affiliation(s)
- Ernest A Fischer
- Division of Hospital Medicine, Department of Medicine, MedStar Georgetown University Hospital, Washington, DC.
| | | | - Kazi A Kalam
- Georgetown University School of Medicine, Washington, DC
| | - Shiavax J Rao
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Md
| | - Jiling Chou
- Center for Biostatistics, Informatics and Data Science, MedStar Health Research Institute, Hyattsville, Md
| | - Luis M Calderon
- Division of Cardiology, Medstar Heart & Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - David S Weisman
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Md
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Dimitriadis K, Damianaki A, Bletsa E, Pyrpyris N, Tsioufis P, Theofilis P, Beneki E, Tatakis F, Kasiakogias A, Oikonomou E, Petras D, Siasos G, Aggeli K, Tsioufis K. Renal Congestion in Heart Failure: Insights in Novel Diagnostic Modalities. Cardiol Rev 2024:00045415-990000000-00224. [PMID: 38427026 DOI: 10.1097/crd.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Heart failure is increasingly prevalent and is estimated to increase its burden in the following years. A well-reported comorbidity of heart failure is renal dysfunction, where predominantly changes in the patient's volume status, tubular necrosis or other mechanical and neurohormonal mechanisms seem to drive this impairment. Currently, there are established biomarkers evaluating the patient's clinical status solely regarding the cardiovascular or renal system. However, as the coexistence of heart and renal failure is common and related to increased mortality and hospitalization for heart failure, it is of major importance to establish novel diagnostic techniques, which could identify patients with or at risk for cardiorenal syndrome and assist in selecting the appropriate management for these patients. Such techniques include biomarkers and imaging. In regards to biomarkers, several peptides and miRNAs indicative of renal or tubular dysfunction seem to properly identify patients with cardiorenal syndrome early on in the course of the disease, while changes in their serum levels can also be helpful in identifying response to diuretic treatment. Current and novel imaging techniques can also identify heart failure patients with early renal insufficiency and assess the volume status and the effect of treatment of each patient. Furthermore, by assessing the renal morphology, these techniques could also help identify those at risk of kidney impairment. This review aims to present all relevant clinical and trial data available in order to provide an up-to-date summary of the modalities available to properly assess cardiorenal syndrome.
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Affiliation(s)
- Kyriakos Dimitriadis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | | | - Evanthia Bletsa
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | - Nikolaos Pyrpyris
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Tsioufis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Theofilis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Eirini Beneki
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Fotis Tatakis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Alexandros Kasiakogias
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | | | - Gerasimos Siasos
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | - Konstantina Aggeli
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Mostafa O. Hepatojugular 'reflex' or 'reflux'? A tale of two vowels. Postgrad Med J 2023; 99:45-46. [PMID: 36825475 DOI: 10.1093/postmj/qgac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/15/2022] [Accepted: 10/01/2022] [Indexed: 01/12/2023]
Abstract
SUMMARY Hepatojugular reflux is an important, prognostic clinical sign in the field of medicine. The majority of medical students or clinicians may attempt to elicit this sign during abdominal or cardiovascular examinations. However, some individuals may incorrectly call it the hepatojugular 'reflex' rather than a 'reflux'. In the first instance, that may not pose a problem to either patient or clinician-however, it may reflect a lack of basic understanding of how the human body works. RELEVANCE
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Affiliation(s)
- Omar Mostafa
- Foundation Year 2 Doctor, Walsall Manor Hospital, Walsall Healthcare NHS Trust, Walsall WS2 9PS, UK
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Abstract
Heart disease is the leading cause of death in the United States with an estimated 6 million adults living with heart failure. In patients with heart failure, the physical examination can provide important prognostic information and is also used to guide both diagnosis and management, including determining the need for inpatient versus outpatient management. Presenting symptoms include dyspnea, peripheral edema, orthopnea, paroxysmal nocturnal dyspnea, and bendopnea. In patients with suspected heart failure, a "head-to-toe" physical examination approach is recommended with the addition of special maneuvers such as the measurement of jugular venous pressure, valsalva maneuver, and hepatojugular reflux as needed.
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Affiliation(s)
- Jennifer Chen
- Department of Internal Medicine, University of California, Davis, 4860 Y Street Suite 0100, Sacramento, CA 95817, USA.
| | - Paul Aronowitz
- Department of Internal Medicine, University of California, Davis, 4150 V Street Suite 3100 PSSB, Sacramento, CA 95817, USA
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Schjødt I, Liljeroos M, Larsen P, Johnsen SP, Strömberg A, Løgstrup BB. Risk factors for hospital readmission in adult patients with heart failure with reduced ejection fraction: a systematic review. JBI Evid Synth 2020; 18:1641-1700. [PMID: 32898362 DOI: 10.11124/jbisrir-d-19-00203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review was to identify and synthesize evidence on risk factors associated with hospital readmission within the first year after heart failure hospitalization among patients with heart failure with reduced left ventricular ejection fraction. INTRODUCTION Heart failure is associated with a high risk of hospital readmission. Readmissions are associated with higher mortality and health care costs. It is a high health care priority to identify vulnerable patients with heart failure who may potentially benefit from targeted personalized care interventions aiming to reduce readmissions. INCLUSION CRITERIA This review considered studies including adult patients who had heart failure with a reduced left ventricular ejection fraction ≤ 40% who were discharged after a heart failure hospitalization. The authors included studies with experimental and observational designs evaluating risk factors for i) all-cause hospital readmission, ii) heart failure hospital readmission, and iii) composite outcomes within seven, 15, 30, 60, 90, 180, and 365 days after hospital discharge. Composite outcomes included end points where all-cause readmission and/or heart failure readmission were part of a defined end point (i.e. all-cause readmission or mortality; heart failure readmission or mortality; cardiovascular readmission; cardiovascular readmission or mortality; and readmission, mortality, or cardiac transplant). Studies reporting all-cause readmission and/or heart failure readmission as a primary outcome, secondary outcome, or part of a composite outcome were included. METHODS PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, OpenGrey, MedNar, DART-Europe, ProQuest Dissertations and Theses, and the Grey Literature Report in Public Health were searched to find both published and unpublished studies in English, Swedish, Norwegian, or Danish from 2000 to June 2018. Study selection, critical appraisal, data extraction, and data synthesis followed the JBI approach for systematic reviews. Statistical pooling was not possible due to clinical and methodological heterogeneity of the studies included and the lack of risk factors reported more than once. A narrative summary of the findings was performed. RESULTS Fifty-two studies, including one randomized controlled trial and 51 cohort studies with a total of 128,186 participants, were included. Risk factors for readmission were reported for 30-day outcome in 16 studies, 60-day in three studies, 90-day in 15 studies, 180-day in 12 studies, and 365-day outcome in 15 studies. Based on multivariable analyses from 43 cohort studies and results from one randomized controlled trial, the authors identified several factors associated with higher risk of all-cause readmission, heart failure readmission, and composite outcomes (e.g. readmission or death) within 30, 60, 90, 180, and 365 days after discharge for a heart failure hospitalization. CONCLUSIONS This review provides a comprehensive overview of factors associated with a clinical outcome after a heart failure hospitalization in patients with heart failure with left ventricular ejection fraction ≤ 40%. Owing to the heterogeneity of variables investigated and the lack of comparability of findings, the clinical impact of the identified risk factors remains uncertain. This review highlights research gaps and the need for a standardized way to define and measure all-cause readmission, heart failure readmission, and composite end points in clinical research to improve study quality and enable comparison of findings between studies.
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Affiliation(s)
- Inge Schjødt
- 1Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark 2Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden 3Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden 4Health Sciences Research Center, University College Lillebælt, Odense, Denmark 5Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark 6Department of Cardiology, Linköping University Hospital, Linköping, Sweden 7Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Thibodeau JT, Drazner MH. The Role of the Clinical Examination in Patients With Heart Failure. JACC-HEART FAILURE 2018; 6:543-551. [PMID: 29885957 DOI: 10.1016/j.jchf.2018.04.005] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 10/14/2022]
Abstract
Despite advances in biomarkers and technology, the clinical examination (i.e., a history and physical examination) remains central in the management of patients with heart failure. Specifically, the clinical examination allows noninvasive assessment of the patient's underlying hemodynamic state, based on whether the patient has elevated ventricular filling pressures and/or an inadequate cardiac index. Such assessments provide important prognostic information and help guide therapeutic decision-making. Herein, the authors critically assess the utility of the clinical examination for these purposes and provide practical tips we have gleaned from our practice in the field of advanced heart failure. The authors note that the ability to assess for congestion is superior to that for inadequate perfusion. Furthermore, in current practice, elevated left ventricular filling pressures are inferred by findings related to an elevated right atrial pressure. They discuss an emerging classification system from the clinical examination that categorizes patients based on whether elevation of ventricular filling pressures occurs on the right side, left side, or both sides.
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Affiliation(s)
- Jennifer T Thibodeau
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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Extent of jugular venous distension and lower extremity edema are the best tools from history and physical examination to identify heart failure exacerbation. Herz 2017; 43:752-758. [PMID: 28993841 DOI: 10.1007/s00059-017-4623-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/05/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION We aimed to identify the best tools from history and physical examination that predict severity of heart failure (HF) exacerbation among patients with an ejection fraction (EF) ≤ 30%. METHODS Patients enrolled in the ESCAPE trial were divided into tertiles according to the combined value of pulmonary capillary wedge pressure (PCWP) and right atrial pressure (RAP) which we used as a marker of volume loading of both pulmonary and systemic compartments. Variables of congestion from history and physical examination were examined across tertiles. RESULTS There were significant differences across tertiles (tertile 1: PCWP + RAP < 31 mm Hg, tertile 2: PCWP + RAP 31-42 mm Hg and tertile 3: PCWP + RAP > 42 mm Hg) with respect to baseline B‑type natriuretic peptide (P = 0.016), blood urea nitrogen (P = 0.022), sodium (P = 0.015), left ventricular ejection fraction (P = 0.005), and inferior vena cava diameter during inspiration (P < 0.001) and expiration (P < 0.001). With respect to variables of congestion from history and physical examination, we found significant differences across tertiles predominantly in signs of right sided failure, specifically, the frequency of jugular venous distension (JVD, P < 0.001) and JVD > 12 cmH2O (p < 0.001), lower extremity edema (P = 0.001) and lower extremity edema of at least grade 2 + (P = 0.029), and positive hepatojugular reflux (HJR, P = 0.022) but no differences in patients' symptoms such as degree of dyspnea, orthopnea or fatigue. With regards to post-discharge outcomes, there was a significant difference across tertiles in all-cause mortality (P = 0.029) and rehospitalization for HF (P = 0.031) at 6 months following randomization. Receiver operator characteristic curves showed that admission PCWP + RAP had an area under the curve of 0.623 (P = 0.0075) and 0.617 (P = 0.0048), respectively, in predicting 6‑month all-cause mortality and rehospitalization for HF. CONCLUSION The presence and extent of JVD and lower extremity edema, and a positive HJR are better than other signs and symptoms in identifying severity of HF exacerbation among patients with EF ≤ 30%.
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