Why do we check hepatojugular reflux (HJR)?

Clinical Significance of Hepatojugular Reflux (HJR) Testing

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

What is Hepatojugular Reflux?

• HJR is assessed by applying pressure to the abdomen while observing for a sustained increase in jugular venous pressure 2
• A positive test is defined as a sustained increase in jugular venous pressure ≥1 cm or 3 cm (depending on the study) during abdominal compression 3, 4
• The test typically stabilizes by 10-15 seconds of compression and does not require longer assessment 3, 4

Clinical Value of HJR Testing

Diagnostic Value

• HJR correlates well with objective hemodynamic markers of volume overload including:

  • Right atrial pressure (RAP) 5
  • Pulmonary capillary wedge pressure (PCWP) 5
  • Inferior vena cava size during both inspiration and expiration 5

• HJR has high specificity (96%) but lower sensitivity (12%) for diagnosing congestive heart failure, making it a valuable "rule-in" test when positive 6

• A positive HJR test has high sensitivity and specificity for predicting:

  • Right atrial pressure >9 mm Hg (sensitivity 1.0, specificity 0.85)
  • Right ventricular end-diastolic pressure >12 mm Hg (sensitivity 0.90, specificity 0.89) 3

Prognostic Value

• A positive HJR on discharge is an independent predictor of 6-month mortality in patients hospitalized with heart failure (hazard ratio: 1.689; 95% CI: 1.032-2.764) 5
• HJR should be routinely checked throughout hospitalization and especially on discharge as it serves as an important prognostic marker for post-discharge outcomes 5

Clinical Applications

• HJR should be assessed at each clinical visit for heart failure patients to guide diuretic therapy and assess response to treatment 2
• HJR provides more reliable information about volume status than peripheral edema, especially in patients with chronic heart failure 1
• 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
• The presence and extent of jugular venous distention, lower extremity edema, and a positive HJR are better than other signs and symptoms in identifying severity of heart failure exacerbation among patients with ejection fraction ≤30% 7

Limitations and Considerations

• 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 1
• Bedside observation of HJR correlates well with measurements during right-sided cardiac catheterization (K = 0.74) 3

Proper Technique for HJR Assessment

• Position the patient at a 45-degree angle
• Apply firm pressure over the right upper quadrant of the abdomen for 10-15 seconds
• Observe the jugular veins for sustained elevation
• A positive test is indicated by a sustained rise in jugular venous pressure of ≥3 cm 4