Indications for Hepatojugular Reflux Testing in Clinical Practice
The hepatojugular reflux (HJR) test should be performed in all patients with suspected heart failure, as it is a reliable and specific physical examination sign for detecting elevated right atrial pressure and volume overload. 1, 2
Primary Indications for HJR Testing
Suspected or established heart failure: HJR should be routinely assessed in patients with symptoms of heart failure as it correlates well with elevated right atrial pressure and pulmonary capillary wedge pressure 1, 3
Evaluation of volume status: HJR should be checked during each clinical visit for heart failure patients to guide diuretic therapy and assess response to treatment 2
Pre-discharge assessment: A positive HJR on discharge is an independent predictor of 6-month mortality in heart failure patients and should be evaluated before hospital discharge 3
Diagnostic uncertainty: When the diagnosis of heart failure is unclear, HJR testing has high specificity for predicting right atrial pressure >9 mmHg (specificity 0.85) and right ventricular end-diastolic pressure >12 mmHg (specificity 0.89) 4
Specific Clinical Scenarios Requiring HJR Testing
Patients with dyspnea of unclear etiology: HJR is useful in predicting congestive heart failure in patients presenting with dyspnea and suggests pulmonary capillary wedge pressures >15 mmHg 5
Suspected right ventricular dysfunction: In patients with signs of right-sided heart failure, HJR should be assessed as it reflects the ability of the right ventricle to accommodate increased venous return 5
Perioperative cardiovascular evaluation: HJR should be checked during preoperative assessment as it provides more reliable information about volume status than peripheral edema, especially in patients with chronic heart failure 1
Patients with liver vascular malformations: HJR should be evaluated in patients with suspected hereditary hemorrhagic telangiectasia (HHT) with liver involvement, as it helps assess the hemodynamic impact of liver vascular malformations 1
Proper Technique for HJR Assessment
Apply sustained abdominal compression for at least 15 seconds (as the response stabilizes by this time) 4, 5
Observe for a sustained increase in jugular venous pressure of ≥3 cm H₂O 6, 5
The test can be performed at the bedside with results that correlate well with measurements during cardiac catheterization 4
Clinical Significance of Positive HJR
A positive HJR indicates elevated right atrial pressure and potential right ventricular dysfunction 1, 4
In heart failure, it serves as a more reliable sign of hypervolemia than peripheral edema, especially when the jugular venous pressure is also elevated 1
The presence of a positive HJR on discharge from a heart failure hospitalization is associated with increased risk of 6-month mortality (hazard ratio: 1.689; 95% CI: 1.032-2.764) 3
Limitations and Considerations
Some studies have questioned the reliability of HJR as a diagnostic sign for heart failure, noting that pressure increases can occur in patients without heart failure 7
Body habitus (especially obesity) may limit the ability to properly assess HJR 1
The test should be interpreted in conjunction with other clinical findings rather than in isolation 2, 5