From the Guidelines
A positive hepatojugular reflex is a clinical sign that indicates right-sided heart failure or volume overload, characterized by an abnormal sustained increase in jugular venous pressure when pressure is applied to the liver. This reflex is a valuable diagnostic tool in clinical practice, helping to identify conditions such as congestive heart failure, tricuspid regurgitation, constrictive pericarditis, or restrictive cardiomyopathy 1. To perform the test, a clinician applies firm pressure over the right upper quadrant of the abdomen for 10-15 seconds while observing the patient's jugular veins. A positive response is noted when the jugular venous pressure rises by at least 3 cm and remains elevated throughout the duration of liver compression. This occurs because the compromised right heart cannot accommodate the additional blood volume pushed from the liver into the central circulation. The hepatojugular reflex is more specific than just observing elevated jugular venous pressure alone and aids clinicians in distinguishing between cardiac and non-cardiac causes of fluid retention or edema.
Some key points to consider when interpreting the hepatojugular reflex include:
- The presence of a systolic murmur at the lower sternal border that increases in intensity with inspiration, and a pulsatile liver edge, which may indicate advanced tricuspid regurgitation 1
- Symptoms such as fatigue from low cardiac output, abdominal fullness, edema, and palpitations, particularly if atrial fibrillation is also present 1
- The importance of using transthoracic echocardiography (TTE) to evaluate the severity of tricuspid regurgitation, determine etiology, measure sizes of right-sided chambers and inferior vena cava, assess RV systolic function, estimate pulmonary artery systolic pressure, and characterize any associated left-sided heart disease 1.
In clinical practice, a positive hepatojugular reflex is a significant finding that warrants further evaluation and management to address the underlying cause of right-sided heart failure or volume overload.
From the Research
Definition of a Positive Hepatojugular Reflex
A positive hepatojugular reflex (HJR) is defined as a sustained increase in jugular venous pressure of greater than 1 cm [ 2 ] or greater than 3 cm [ 3 ] in response to sustained abdominal compression, typically lasting for more than 15 seconds.
Clinical Significance
The presence of a positive HJR has been correlated with various clinical and hemodynamic markers of volume overload, including:
- Right atrial pressure [ 2 ], [ 4 ]
- Pulmonary capillary wedge pressure [ 4 ]
- Inferior vena cava size [ 4 ]
- Left ventricular diastolic dysfunction [ 5 ]
Prognostic Value
A positive HJR has been shown to be an independent predictor of:
- 6-month mortality in patients with acute heart failure [ 4 ]
- All-cause death and hospitalization for worsening heart failure [ 6 ]
Causes of a Positive Hepatojugular Reflex
A positive HJR can be caused by various conditions, including:
- Constrictive pericarditis
- Right ventricular infarction
- Restrictive cardiomyopathy
- Left ventricular failure with pulmonary capillary wedge pressure greater than 15 mmHg [ 3 ]