What is Hepatojugular Reflux?
For many years, diagnosing and managing congestive heart failure (CHF), a condition where the heart can’t pump blood as well as it should, has relied on a thorough examination of the patient’s medical history and a physical check-up. However, with the development of non-invasive imaging techniques over the past few decades, the accuracy of a simple physical exam has been brought into question.
In spite of this, basic physical exam techniques, like the hepatojugular reflux (HJR) test, remain useful tools. This test can assist in diagnosing and managing CHF. Hepatojugular reflux first caught the attention of the medical world in 1885 when Pasteur described it as a physical sign of tricuspid regurgitation, a condition where the heart’s valve doesn’t close tightly enough and allows blood to flow back into the heart.
What Causes Hepatojugular Reflux?
Research has shown that a positive hepatojugular reflux, or when blood in the neck veins increases due to pressure on the abdomen, can be linked to a number of heart conditions. Some studies have found it to be more associated with left-sided heart failure, while others have found it to be more associated with the right side.
Significant relationships have been seen between a positive hepatojugular reflux and increased pressure in the right atrium of the heart (the chamber where deoxygenated blood from the body enters the heart), the pulmonary capillary (tiny blood vessels in the lungs), the pulmonary artery (the major artery leading from the heart to the lungs). This suggests that hepatojugular reflux could be an indicator of high pressure on both sides of the heart.
So, a positive hepatojugular reflux does not specifically diagnose a certain condition. Instead, it indicates that the right side of the heart is having difficulty coping with an increased amount of blood coming back to it. Conditions that often result in a positive hepatojugular reflux include constrictive pericarditis (a disease where the lining around the heart becomes rigid and constrains its movements), right ventricular failure (often due to a heart attack), and restrictive cardiomyopathy (a disease that makes it hard for the heart to stretch and fill with blood).
Left ventricular failure can also cause this sign, but usually only when the pressure in the tiny blood vessels in the lungs is higher than normal. One condition, cardiac tamponade, where fluid builds up around the heart and affects its ability to pump blood, oddly does not usually result in a positive hepatojugular reflux.
Risk Factors and Frequency for Hepatojugular Reflux
Congestive heart failure (CHF) is a widespread health condition, impacting over 25 million people globally. In the United States alone, CHF is responsible for about 1 million hospitalizations every year, causing healthcare costs to soar to nearly $17 billion. Despite treatment efforts, CHF has alarmingly high sickness and death rates, with over 50% of patients being readmitted to the hospital within 6 months of their original discharge. Often, these patients are readmitted because of an issue known as volume overload, which can sometimes be detected at the time of discharge. There is a simple, non-invasive test, known as the hepatojugular reflux, that can help diagnose volume overload in patients with CHF right at their bedside.
- Congestive heart failure (CHF) affects over 25 million people worldwide.
- In the United States, CHF leads to about 1 million hospitalizations per year.
- The healthcare costs associated with CHF near $17 billion.
- High sickness and death rates are associated with CHF, with over 50% of patients being readmitted within 6 months of discharge.
- Volume overload is often the cause of these readmissions and can sometimes be identified at the time of discharge.
- A simple, non-invasive test called the hepatojugular reflux can diagnose volume overload in CHF patients.
Signs and Symptoms of Hepatojugular Reflux
If the patient is being tested for hepatojugular reflux, there are specific steps to follow. They should be positioned so their jugular venous pressure (JVP) can be easily seen. This usually involves laying them at an angle with the head of the bed tilted 30 to 45 degrees upwards. Their uppermost JVP should be about 3 cm away from the angle of their jaw.
Next, steady pressure of around 20 to 35 mmHg is applied to their abdomen. This used to be done for 15 seconds, but recent studies suggest that 10 seconds might be enough. The exact spot where pressure is applied doesn’t really matter. It doesn’t have to be directly on the liver because pressure anywhere in the midriff area will increase intra-abdominal pressure. Not pressing directly on the liver might even be better because it can be uncomfortable to the patient.
If any additional pressure causes the JVP to stay elevated by more than 3 cm, it would be a positive sign of hepatojugular reflux. An increase of 1 to 3 cm is considered normal. Some medical professionals think it can be hard to correctly place the patient and recommend having them sit upright at 90 degrees. In this position, the collarbone would be about 10 cm above the right atrium. If the JVP rises above the collarbone and stays there for 10 seconds or more, it’s considered a positive test.
Testing for Hepatojugular Reflux
A research study analyzing data from the ESCAPE trial stressed the need to check for hepatojugular reflux in patients hospitalized with heart failure. The hepatojugular reflux is an easy-to-check physical sign, with a high agreement of around 97% amongst different observers. This sign was found to strongly correlate with observable signs of congestion and levels of brain natriuretic peptide, a substance that your heart and blood vessels produce when they are experiencing stress.
The study also found this sign to correlate positively with key markers of excessive fluid in the body: the pressures in the pulmonary capillaries (small blood vessels in the lungs) and right atrium (the upper right chamber of the heart), which are typically higher in people with heart failure.
Previous research has highlighted the usefulness of hepatojugular reflux in predicting heart failure in patients experiencing shortness of breath. These studies also suggested that if the patient had a hepatojugular reflux and their pulmonary capillary wedge pressure measurement is equal to or greater than 15 mmHg, then the presence of heart failure is very likely. These findings were confirmed in the recent study, which also found that a positive hepatojugular reflux sign was associated with a larger inferior vena cava diameter, a measurement that accurately reflects a patient’s fluid levels and can help predict worsening heart failure.
The study also found that patients who still had a hepatojugular reflux sign when they were discharged from the hospital had a significantly higher chance of dying within the next six months compared to patients whose hepatojugular reflux sign disappeared.
Additionally, the study examined the impact of having both a positive hepatojugular reflux sign and jugular venous distention (a condition where the jugular vein is larger than normal, indicating high blood pressure in the vein) on patient outcomes after they were discharged from the hospital. Patients with both conditions had a higher mortality rate in the next six months compared to patients who only had a positive hepatojugular reflux sign.
What else can Hepatojugular Reflux be?
Here are some heart-related conditions that might need to be considered:
- Arterial flutter
- Arterial fibrillation
- Atrioventricular dissociation
- Cardiac tamponade
- Constructive pericarditis
- First-degree atrioventricular block
- Pulmonary hypertension
- Right atrial myxoma (a type of heart tumor)
- Tricuspid stenosis (narrowing of a heart valve)
- Tricuspid regurgitation (failure of a heart valve to close properly)
